Provider Demographics
NPI:1558675249
Name:CLARK, THOMAS MONROE (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MONROE
Last Name:CLARK
Suffix:
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 1:2404 WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-1146
Mailing Address - Country:US
Mailing Address - Phone:864-244-0400
Mailing Address - Fax:884-292-9463
Practice Address - Street 1:2404 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1146
Practice Address - Country:US
Practice Address - Phone:864-244-0400
Practice Address - Fax:884-292-9463
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist