Provider Demographics
NPI:1174636419
Name:CLARK, BRENT WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3935 BITTER SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1598
Mailing Address - Country:US
Mailing Address - Phone:816-838-5663
Mailing Address - Fax:
Practice Address - Street 1:390 NORTH LOOP RD.
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-383-5289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry