Provider Demographics
NPI:1710117999
Name:TRISCHA A. CLARKE D.D.S., P.L.L.C.
Entity Type:Organization
Organization Name:TRISCHA A. CLARKE D.D.S., P.L.L.C.
Other - Org Name:DIVINE DENTAL WORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRISCHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-630-4155
Mailing Address - Street 1:427 STONE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-1026
Mailing Address - Country:US
Mailing Address - Phone:918-630-4155
Mailing Address - Fax:
Practice Address - Street 1:427 STONE WOOD DR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1026
Practice Address - Country:US
Practice Address - Phone:918-630-4155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5859261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental