Provider Demographics
NPI:1225341415
Name:CLARK, THOMAS (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:29292 SW TOWN CENTER LOOP E
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9491
Mailing Address - Country:US
Mailing Address - Phone:506-682-0431
Mailing Address - Fax:503-682-3873
Practice Address - Street 1:29292 SW TOWN CENTER LOOP E
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9491
Practice Address - Country:US
Practice Address - Phone:506-682-0431
Practice Address - Fax:503-682-3873
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD94601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice