Provider Demographics
NPI:1205843604
Name:CLARK, EDWARD MARK (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARK
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 YELLOWSTONE RD
Mailing Address - Street 2:STE # 1
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4761
Mailing Address - Country:US
Mailing Address - Phone:307-634-7633
Mailing Address - Fax:307-634-7664
Practice Address - Street 1:5211 YELLOWSTONE RD
Practice Address - Street 2:STE # 1
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4761
Practice Address - Country:US
Practice Address - Phone:307-634-7633
Practice Address - Fax:307-634-7664
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice