Provider Demographics
NPI:1528372133
Name:CLARK, RYAN GREGORY (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:GREGORY
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 1146
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-1146
Mailing Address - Country:US
Mailing Address - Phone:304-263-4999
Mailing Address - Fax:304-263-0984
Practice Address - Street 1:58 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-3800
Practice Address - Country:US
Practice Address - Phone:304-263-4999
Practice Address - Fax:304-163-4999
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011515A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist