Provider Demographics
NPI:1154052843
Name:CLARK, MICHELLE RAE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2138
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81612-2138
Mailing Address - Country:US
Mailing Address - Phone:352-871-2870
Mailing Address - Fax:
Practice Address - Street 1:2014 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4229
Practice Address - Country:US
Practice Address - Phone:970-625-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH002026398124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist