Provider Demographics
NPI:1720204803
Name:PERRY, MARK CLAWSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CLAWSON
Last Name:PERRY
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 1:7725 91ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3944
Mailing Address - Country:US
Mailing Address - Phone:253-581-7098
Mailing Address - Fax:
Practice Address - Street 1:8412 83RD AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-6074
Practice Address - Country:US
Practice Address - Phone:253-588-6208
Practice Address - Fax:253-582-0626
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000058611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5029780Medicaid