Provider Demographics
NPI:1790734796
Name:CLARK, TANNER JAY (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:JAY
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 W. CHERRY ST.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317
Mailing Address - Country:US
Mailing Address - Phone:319-626-3161
Mailing Address - Fax:
Practice Address - Street 1:650 W. CHERRY ST.
Practice Address - Street 2:SUITE 5
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317
Practice Address - Country:US
Practice Address - Phone:319-626-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088801223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics