Provider Demographics
NPI:1467931352
Name:CLARK, ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
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 1:2159 BELLA OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-7760
Mailing Address - Country:US
Mailing Address - Phone:559-495-8085
Mailing Address - Fax:
Practice Address - Street 1:4129 S MOONEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9147
Practice Address - Country:US
Practice Address - Phone:559-732-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1028901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS102890OtherCALIFORNIA DENTAL LICENSE