Provider Demographics
NPI:1629040183
Name:CLARK, PHILIP RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RICHARD
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 1:4503 SEAHURST AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-1717
Mailing Address - Country:US
Mailing Address - Phone:425-252-2180
Mailing Address - Fax:
Practice Address - Street 1:5929 EVERGREEN WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-6031
Practice Address - Country:US
Practice Address - Phone:425-353-4469
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA70621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice