Provider Demographics
NPI:1356639892
Name:CLARK, RYAN JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JAMES
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 1:580 W PARKCENTER BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-336-8478
Mailing Address - Fax:208-342-2703
Practice Address - Street 1:580 W PARKCENTER BLVD STE B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-336-8478
Practice Address - Fax:208-342-2703
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID43751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice