Provider Demographics
NPI:1568831279
Name:CLARK, RILEY DEAN (DMD)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:DEAN
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 1:380 E 1500 S STE 205
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3942
Mailing Address - Country:US
Mailing Address - Phone:435-657-2105
Mailing Address - Fax:435-709-3079
Practice Address - Street 1:380 E 1500 S STE 205
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3942
Practice Address - Country:US
Practice Address - Phone:435-657-2105
Practice Address - Fax:435-709-3079
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9053425-89031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice