Provider Demographics
NPI:1306027529
Name:ROBERT S CLARK DDS
Entity Type:Organization
Organization Name:ROBERT S CLARK DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-826-7577
Mailing Address - Street 1:31 SCHOOSETT STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359
Mailing Address - Country:US
Mailing Address - Phone:781-826-7577
Mailing Address - Fax:781-826-8970
Practice Address - Street 1:31 SCHOOSETT STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359
Practice Address - Country:US
Practice Address - Phone:781-826-7577
Practice Address - Fax:781-826-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA131901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0248126Medicaid