Provider Demographics
NPI:1598285777
Name:CLARK ORAL SURGERY AND IMPLANT CENTER
Entity Type:Organization
Organization Name:CLARK ORAL SURGERY AND IMPLANT CENTER
Other - Org Name:DR. TYLER L. CLARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTRANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-245-1100
Mailing Address - Street 1:9430 SW CORAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6692
Mailing Address - Country:US
Mailing Address - Phone:503-245-1100
Mailing Address - Fax:503-473-8300
Practice Address - Street 1:9430 SW CORAL ST STE 200
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6692
Practice Address - Country:US
Practice Address - Phone:503-245-1100
Practice Address - Fax:503-473-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10177261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental