Provider Demographics
NPI:1568732048
Name:BRADLEY P CLARK DDS INC
Entity Type:Organization
Organization Name:BRADLEY P CLARK DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:416-781-2674
Mailing Address - Street 1:450 SUTTER ST
Mailing Address - Street 2:SUITE 2109
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-781-2674
Mailing Address - Fax:
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:SUITE 2109
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-781-2674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC7844562OtherDEA REGISTRATION