Provider Demographics
NPI:1477501419
Name:CLARK, STEPHEN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
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 1:102 PONEMAH RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-2827
Mailing Address - Country:US
Mailing Address - Phone:603-673-7950
Mailing Address - Fax:603-672-7647
Practice Address - Street 1:102 PONEMAH RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NH
Practice Address - Zip Code:03031-2827
Practice Address - Country:US
Practice Address - Phone:603-673-7950
Practice Address - Fax:603-672-7647
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH89191000Medicaid
NH89191000Medicaid