Provider Demographics
NPI:1750327318
Name:CLARK, DEAN ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ALLEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 SW MACADAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3647
Mailing Address - Country:US
Mailing Address - Phone:503-244-3389
Mailing Address - Fax:
Practice Address - Street 1:6105 S.W. MACADAM AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3264
Practice Address - Country:US
Practice Address - Phone:503-244-3389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1856111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician