Provider Demographics
NPI:1639264732
Name:CLARK DENTAL GROUP, P.A.
Entity Type:Organization
Organization Name:CLARK DENTAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-291-4281
Mailing Address - Street 1:211 W BELT LINE RD
Mailing Address - Street 2:SOUTH SUITE
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2066
Mailing Address - Country:US
Mailing Address - Phone:972-291-4281
Mailing Address - Fax:972-291-6466
Practice Address - Street 1:211 W BELT LINE RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2066
Practice Address - Country:US
Practice Address - Phone:972-291-4281
Practice Address - Fax:972-291-6466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty