Provider Demographics
NPI:1225449671
Name:CLARK, DUSTIN J (DC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S RACE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6400
Mailing Address - Country:US
Mailing Address - Phone:360-452-7636
Mailing Address - Fax:
Practice Address - Street 1:601 S RACE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6400
Practice Address - Country:US
Practice Address - Phone:360-452-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.60465702111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor