Provider Demographics
NPI:1689730533
Name:CLARK, BRIAN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERT
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 1:228 W 200 S STE 1A
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036-9010
Mailing Address - Country:US
Mailing Address - Phone:435-783-2273
Mailing Address - Fax:435-783-4357
Practice Address - Street 1:228 W 200 S STE 1A
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-9010
Practice Address - Country:US
Practice Address - Phone:435-783-2273
Practice Address - Fax:435-783-4357
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109740381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice