Provider Demographics
NPI:1437321536
Name:CLARK, DAVID M (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:801 S PAULINA ST
Mailing Address - Street 2:M/C 621, ROOM 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:312-996-1036
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:M/C 621, ROOM 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-1036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019026683Medicaid