Provider Demographics
NPI:1679841811
Name:CLARK, TANNER MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:MARK
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 FITZWATER ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1132
Mailing Address - Country:US
Mailing Address - Phone:208-317-8555
Mailing Address - Fax:
Practice Address - Street 1:2203 FITZWATER ST UNIT 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1132
Practice Address - Country:US
Practice Address - Phone:208-317-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0389101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice