Provider Demographics
NPI:1497803803
Name:CLARK, JAN DEAN (DMD)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:DEAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NO WILLSON
Mailing Address - Street 2:602F
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-586-5318
Mailing Address - Fax:406-586-1635
Practice Address - Street 1:300 NO WILLSON
Practice Address - Street 2:602F
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-586-5318
Practice Address - Fax:406-586-1635
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT79213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0390091Medicaid
MT0390091Medicaid