Provider Demographics
NPI:1144228875
Name:DANIEL J. CLARK, DDS, INC.
Entity Type:Organization
Organization Name:DANIEL J. CLARK, DDS, INC.
Other - Org Name:CLARK FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-393-3494
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133
Mailing Address - Country:US
Mailing Address - Phone:937-393-3494
Mailing Address - Fax:937-393-6864
Practice Address - Street 1:624 SOUTH HIGH STREET
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133
Practice Address - Country:US
Practice Address - Phone:937-393-3494
Practice Address - Fax:937-393-6864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15180122300000X
OH18843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0854375Medicaid
792420OtherUNITED HEALTHCARE