Provider Demographics
NPI:1578542361
Name:CLARK, TYLER LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:LEE
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 1:330 S GARDEN WAY
Mailing Address - Street 2:STE 140
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8176
Mailing Address - Country:US
Mailing Address - Phone:541-686-9750
Mailing Address - Fax:541-485-5034
Practice Address - Street 1:330 S GARDEN WAY
Practice Address - Street 2:STE 140
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8176
Practice Address - Country:US
Practice Address - Phone:541-686-9750
Practice Address - Fax:541-485-5034
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD101771223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500684192Medicaid
OR500684192Medicaid