Provider Demographics
NPI:1497713176
Name:L L CLARK DDS SC
Entity Type:Organization
Organization Name:L L CLARK DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-375-4549
Mailing Address - Street 1:105 EAST BLUFF STREET
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-9802
Mailing Address - Country:US
Mailing Address - Phone:608-375-4549
Mailing Address - Fax:608-375-4665
Practice Address - Street 1:105 EAST BLUFF STREET
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-9802
Practice Address - Country:US
Practice Address - Phone:608-375-4549
Practice Address - Fax:608-375-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50016780151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33549200Medicaid