Provider Demographics
NPI:1891201018
Name:CLARK FAMILY DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:CLARK FAMILY DENTAL CENTER, LLC
Other - Org Name:SPIEKER DENTAL, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:SPIEKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-532-3636
Mailing Address - Street 1:415 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:SD
Mailing Address - Zip Code:57225-1320
Mailing Address - Country:US
Mailing Address - Phone:605-532-3636
Mailing Address - Fax:
Practice Address - Street 1:415 1ST AVE W
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:SD
Practice Address - Zip Code:57225-1320
Practice Address - Country:US
Practice Address - Phone:605-532-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDDL141108261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental