Provider Demographics
NPI:1558420638
Name:CLARK, ROBERT WALLACE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WALLACE
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11169 W ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85363-1228
Mailing Address - Country:US
Mailing Address - Phone:623-933-2971
Mailing Address - Fax:623-972-4420
Practice Address - Street 1:11169 W ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:YOUNGTOWN
Practice Address - State:AZ
Practice Address - Zip Code:85363-1228
Practice Address - Country:US
Practice Address - Phone:623-933-2971
Practice Address - Fax:623-972-4420
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ2129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist