Provider Demographics
NPI:1710008248
Name:CLARK, ROBERT L (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
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 1:215 N PITTSBURGH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-3209
Mailing Address - Country:US
Mailing Address - Phone:724-628-8110
Mailing Address - Fax:724-628-8802
Practice Address - Street 1:215 N PITTSBURGH ST
Practice Address - Street 2:SUITE B
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3209
Practice Address - Country:US
Practice Address - Phone:724-628-8110
Practice Address - Fax:724-628-8802
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-024925L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice