Provider Demographics
NPI:1386868370
Name:CLARK, DENNIS P (DMD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:P
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9430 SW CORAL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6691
Mailing Address - Country:US
Mailing Address - Phone:503-245-1100
Mailing Address - Fax:
Practice Address - Street 1:9430 SW CORAL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6691
Practice Address - Country:US
Practice Address - Phone:503-245-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD78291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery