Provider Demographics
NPI:1790253383
Name:CLARK, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1178
Mailing Address - Country:US
Mailing Address - Phone:315-408-0413
Mailing Address - Fax:
Practice Address - Street 1:1156 COOK ST.
Practice Address - Street 2:
Practice Address - City:DANNEMORA
Practice Address - State:NY
Practice Address - Zip Code:12929
Practice Address - Country:US
Practice Address - Phone:518-492-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029980124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist