Provider Demographics
NPI:1902193253
Name:CLARK, DAVID MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MATTHEW
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 1:2180 E 4500 S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4434
Mailing Address - Country:US
Mailing Address - Phone:801-272-8609
Mailing Address - Fax:
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:SUITE 250
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-272-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5606768-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice