Provider Demographics
NPI:1619985884
Name:CLARK, ALAN DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:DOUGLAS
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 1:745 E. JOYCE
Mailing Address - Street 2:STE 221
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-443-1849
Mailing Address - Fax:479-443-2034
Practice Address - Street 1:745 E. JOYCE
Practice Address - Street 2:STE 221
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-443-1849
Practice Address - Fax:479-443-2034
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR870436704OtherOLD TAX ID #
AR412175658OtherNEW TAX ID #
AR143894608Medicaid