Provider Demographics
NPI:1114380094
Name:JOHN A LARK DDS PC
Entity Type:Organization
Organization Name:JOHN A LARK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCMORDIE
Authorized Official - Suffix:
Authorized Official - Credentials:EFDA
Authorized Official - Phone:517-263-9022
Mailing Address - Street 1:1136 COUNTRY CLUB
Mailing Address - Street 2:SUITE B
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221
Mailing Address - Country:US
Mailing Address - Phone:517-263-9022
Mailing Address - Fax:517-263-9155
Practice Address - Street 1:1136 COUNTRY CLUB RD
Practice Address - Street 2:SUITE B
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-8208
Practice Address - Country:US
Practice Address - Phone:517-263-9022
Practice Address - Fax:517-263-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty