Provider Demographics
NPI:1407360910
Name:CLARK, GRACE XINXING (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:XINXING
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 BROOKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-5417
Mailing Address - Country:US
Mailing Address - Phone:812-251-6241
Mailing Address - Fax:
Practice Address - Street 1:4716 ILLINOIS RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5123
Practice Address - Country:US
Practice Address - Phone:260-432-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012818A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice