Provider Demographics
NPI:1114197456
Name:CLARK, ALAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:A
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 1:15898 BUSH RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9201
Mailing Address - Country:US
Mailing Address - Phone:530-478-1144
Mailing Address - Fax:530-478-0711
Practice Address - Street 1:15898 BUSH RD
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-9201
Practice Address - Country:US
Practice Address - Phone:530-478-1144
Practice Address - Fax:530-478-0711
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADZ190441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice