Provider Demographics
NPI:1093790396
Name:CLARK, MIKE L (DDS)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:L
Last Name:CLARK
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 1:1012 S 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3804
Mailing Address - Country:US
Mailing Address - Phone:509-966-9253
Mailing Address - Fax:509-966-6595
Practice Address - Street 1:1012 S 40TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3804
Practice Address - Country:US
Practice Address - Phone:509-966-9253
Practice Address - Fax:509-966-6595
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000100041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice