Provider Demographics
NPI:1689759516
Name:CLARK, TERESA MARIE (RDA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7218 BIRCH BARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37062
Mailing Address - Country:US
Mailing Address - Phone:615-799-5438
Mailing Address - Fax:
Practice Address - Street 1:7218 BIRCH BARK DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062
Practice Address - Country:US
Practice Address - Phone:615-799-5438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3436126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant