Provider Demographics
NPI:1891007902
Name:SMITH, CLARK ELON (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:ELON
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-6521
Mailing Address - Country:US
Mailing Address - Phone:781-356-3030
Mailing Address - Fax:
Practice Address - Street 1:102 PEARL ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-6521
Practice Address - Country:US
Practice Address - Phone:781-356-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6556-151223X0400X
MADN18559461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics