Provider Demographics
NPI:1831103308
Name:CLARK, DAVID JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
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 1:211 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MARSHALLTOWN
Mailing Address - State:IA
Mailing Address - Zip Code:50158
Mailing Address - Country:US
Mailing Address - Phone:641-752-3651
Mailing Address - Fax:641-752-3653
Practice Address - Street 1:211 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158
Practice Address - Country:US
Practice Address - Phone:641-752-3651
Practice Address - Fax:641-752-3653
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA068231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0207472Medicaid