Provider Demographics
NPI:1477571677
Name:CLARK, ALBERT BAXTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:BAXTER
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 1:1355 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-375-1750
Mailing Address - Fax:801-375-6365
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-375-1750
Practice Address - Fax:801-375-6365
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139191-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice