Provider Demographics
NPI:1407095383
Name:CLARKE, BRUCE RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RICHARD
Last Name:CLARKE
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 1:203 NORTH SECOND AVE
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118
Mailing Address - Country:US
Mailing Address - Phone:518-664-7348
Mailing Address - Fax:
Practice Address - Street 1:203 NORTH SECOND AVE
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118
Practice Address - Country:US
Practice Address - Phone:518-664-7348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist