Provider Demographics
NPI:1861471153
Name:CLARK, MARTIN THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:THOMAS
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 1:3475 N SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98278-4927
Mailing Address - Country:US
Mailing Address - Phone:360-257-4478
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-4927
Practice Address - Country:US
Practice Address - Phone:360-257-4478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00133171223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics