Provider Demographics
NPI:1093930281
Name:CLARK, STARLA D (DDS)
Entity Type:Individual
Prefix:DR
First Name:STARLA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 MONTGOMERY RD
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5201
Mailing Address - Country:US
Mailing Address - Phone:513-984-0888
Mailing Address - Fax:513-984-0411
Practice Address - Street 1:10475 MONTGOMERY RD
Practice Address - Street 2:SUITE 2E
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-5201
Practice Address - Country:US
Practice Address - Phone:513-984-0888
Practice Address - Fax:513-984-0411
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist