Provider Demographics
NPI:1699845636
Name:CLARK, LEON MALCOLM JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:MALCOLM
Last Name:CLARK
Suffix:JR
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 1:203B COMMERCE CIRCLE SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601
Mailing Address - Country:US
Mailing Address - Phone:256-350-8182
Mailing Address - Fax:256-350-3232
Practice Address - Street 1:203B COMMERCE CIRCLE SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:256-350-8182
Practice Address - Fax:256-350-3232
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice