Provider Demographics
NPI:1093729618
Name:REDD, CLARK WARREN (DDS)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:WARREN
Last Name:REDD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6808 220TH ST SW
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2187
Mailing Address - Country:US
Mailing Address - Phone:425-670-3995
Mailing Address - Fax:425-670-8065
Practice Address - Street 1:6808 220TH ST SW
Practice Address - Street 2:SUITE 301
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2187
Practice Address - Country:US
Practice Address - Phone:425-670-3995
Practice Address - Fax:425-670-8065
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA66771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice