Provider Demographics
NPI:1730116112
Name:TERRE HAUTE ENDODONTICS PC
Entity Type:Organization
Organization Name:TERRE HAUTE ENDODONTICS PC
Other - Org Name:DR PATRICIA H CLARK
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DR PATRICIA H CLARK
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:H
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:812-235-1598
Mailing Address - Street 1:221 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4129
Mailing Address - Country:US
Mailing Address - Phone:812-235-1598
Mailing Address - Fax:812-235-1999
Practice Address - Street 1:221 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4129
Practice Address - Country:US
Practice Address - Phone:812-235-1598
Practice Address - Fax:812-235-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100065720AMedicaid