Provider Demographics
NPI:1821202383
Name:CLARK, ROGER E (DDS)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:CLARK
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 1:736 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1608
Mailing Address - Country:US
Mailing Address - Phone:513-932-1370
Mailing Address - Fax:513-932-0814
Practice Address - Street 1:736 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1608
Practice Address - Country:US
Practice Address - Phone:513-932-1370
Practice Address - Fax:513-932-0814
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH137951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice