Provider Demographics
NPI:1720202203
Name:SWEENEY, CLARK REGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:REGAN
Last Name:SWEENEY
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:PO BOX 1881
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1881
Mailing Address - Country:US
Mailing Address - Phone:414-288-6212
Mailing Address - Fax:414-288-8361
Practice Address - Street 1:1801 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2186
Practice Address - Country:US
Practice Address - Phone:414-288-6212
Practice Address - Fax:414-288-8361
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50018641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery