Provider Demographics
NPI:1235344052
Name:CLARK, JOHN WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WARREN
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 1:8 MONUMENT SQUARE LN
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-1339
Mailing Address - Country:US
Mailing Address - Phone:207-564-8197
Mailing Address - Fax:207-564-8489
Practice Address - Street 1:8 MONUMENT SQUARE LN
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1339
Practice Address - Country:US
Practice Address - Phone:207-564-8197
Practice Address - Fax:207-564-8489
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist