Provider Demographics
NPI:1568439107
Name:CLARK, LINDBERG (DMD)
Entity Type:Individual
Prefix:DR
First Name:LINDBERG
Middle Name:
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 475
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533
Mailing Address - Country:US
Mailing Address - Phone:228-374-2494
Mailing Address - Fax:228-374-2713
Practice Address - Street 1:15024 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-864-0003
Practice Address - Fax:228-864-8553
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS204683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0060061Medicaid