Provider Demographics
NPI:1487644183
Name:CLARK, STEPHEN B (DDS,MS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N DUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6101
Mailing Address - Country:US
Mailing Address - Phone:505-327-4495
Mailing Address - Fax:505-325-9125
Practice Address - Street 1:701 N DUSTIN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6101
Practice Address - Country:US
Practice Address - Phone:505-327-4495
Practice Address - Fax:505-325-9125
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0006258Medicaid
NM00081208Medicaid