Provider Demographics
NPI:1588001135
Name:CLARK, FREDRIC E (DDS,MSD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 SE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66607-2204
Mailing Address - Country:US
Mailing Address - Phone:785-233-2800
Mailing Address - Fax:785-233-5116
Practice Address - Street 1:3164 SE 6TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66607-2204
Practice Address - Country:US
Practice Address - Phone:785-233-2800
Practice Address - Fax:785-233-5116
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS38971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery