Provider Demographics
NPI:1376655357
Name:DRS PETER AND LISA CLARK FAMILY AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:DRS PETER AND LISA CLARK FAMILY AND COSMETIC DENTISTRY
Other - Org Name:BONHAM FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:903-583-8023
Mailing Address - Street 1:101 E 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418
Mailing Address - Country:US
Mailing Address - Phone:903-583-8023
Mailing Address - Fax:903-583-1291
Practice Address - Street 1:101 E 9TH STREET
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418
Practice Address - Country:US
Practice Address - Phone:903-583-8023
Practice Address - Fax:903-583-1291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203411223G0001X
TX203401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1318239OtherUNITED CONCORDIA