Provider Demographics
NPI:1336508092
Name:CLARK, PATRICK J (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:J
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 1:548 SHERIDAN RD APT 2N
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4719
Mailing Address - Country:US
Mailing Address - Phone:253-241-8160
Mailing Address - Fax:
Practice Address - Street 1:7603 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1133
Practice Address - Country:US
Practice Address - Phone:708-456-7787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0320401223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics