Provider Demographics
NPI:1689764805
Name:CLARK, DAVID MANTELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MANTELL
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 1:4816 MACMONT CIR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-4500
Mailing Address - Country:US
Mailing Address - Phone:865-938-8236
Mailing Address - Fax:
Practice Address - Street 1:4816 MACMONT CIR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4500
Practice Address - Country:US
Practice Address - Phone:865-938-8236
Practice Address - Fax:865-689-4080
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 20971223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics