Provider Demographics
NPI:1669005955
Name:CLARK DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:CLARK DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-317-8555
Mailing Address - Street 1:10597 S BEACH COMBER WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-6132
Mailing Address - Country:US
Mailing Address - Phone:484-278-1169
Mailing Address - Fax:
Practice Address - Street 1:9844 S 1300 E STE 360
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4698
Practice Address - Country:US
Practice Address - Phone:801-571-6999
Practice Address - Fax:801-576-7507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty