Provider Demographics
NPI:1407252679
Name:CLARK, BRADLEY (DDS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
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 1:450 SUTTER ST
Mailing Address - Street 2:SUITE 2109
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-781-2674
Mailing Address - Fax:
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:SUITE 2109
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-781-2674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA268251223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC7844562OtherDEA