Provider Demographics
NPI:1508906751
Name:CLARK, BRENT GILFORD (DMD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:GILFORD
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:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BETSY LAYNE
Mailing Address - State:KY
Mailing Address - Zip Code:41605-0001
Mailing Address - Country:US
Mailing Address - Phone:606-478-9090
Mailing Address - Fax:606-478-9191
Practice Address - Street 1:US 23 HAYES COMPLEX
Practice Address - Street 2:
Practice Address - City:BETSY LAYNE
Practice Address - State:KY
Practice Address - Zip Code:41605-0001
Practice Address - Country:US
Practice Address - Phone:606-478-9090
Practice Address - Fax:606-478-9191
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49801223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics