Provider Demographics
NPI:1215225305
Name:CLARK, ASHLEY NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9292 N MERIDIAN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1828
Mailing Address - Country:US
Mailing Address - Phone:317-843-2204
Mailing Address - Fax:317-843-2478
Practice Address - Street 1:9292 N MERIDIAN ST STE 210
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1828
Practice Address - Country:US
Practice Address - Phone:317-843-2204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10417122300000X, 1223P0106X
IN12011677A1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No122300000XDental ProvidersDentist