Provider Demographics
NPI:1164800801
Name:CLARK, H. III
Entity Type:Individual
Prefix:
First Name:H.
Middle Name:
Last Name:CLARK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5260
Mailing Address - Country:US
Mailing Address - Phone:715-392-5161
Mailing Address - Fax:715-392-7474
Practice Address - Street 1:2101 HILL AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5260
Practice Address - Country:US
Practice Address - Phone:715-392-5161
Practice Address - Fax:715-392-7474
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5751-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12OtherDENTAL