Provider Demographics
NPI:1902007354
Name:GARY K. CLARK, DMD & ASSOC., PC
Entity Type:Organization
Organization Name:GARY K. CLARK, DMD & ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-572-1130
Mailing Address - Street 1:9730 S 700 E STE 106
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9730 S 700 E STE 106
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4503
Practice Address - Country:US
Practice Address - Phone:801-572-1130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141551-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty