Provider Demographics
NPI:1891777207
Name:CLARK, TONYA ELAINE (RDHAP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:ELAINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1786 BANNON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-1518
Mailing Address - Country:US
Mailing Address - Phone:916-283-5622
Mailing Address - Fax:916-283-5622
Practice Address - Street 1:1786 BANNON CREEK DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-1518
Practice Address - Country:US
Practice Address - Phone:916-952-5620
Practice Address - Fax:916-283-5622
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist