Provider Demographics
NPI:1942249545
Name:CLARK, RICHARD JAMES III (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAMES
Last Name:CLARK
Suffix:III
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 1:2300 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1102
Mailing Address - Country:US
Mailing Address - Phone:610-623-4211
Mailing Address - Fax:610-623-2850
Practice Address - Street 1:2300 GARRETT RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1102
Practice Address - Country:US
Practice Address - Phone:610-623-4211
Practice Address - Fax:610-623-2850
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024574L1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1172921Medicaid
PA1172921Medicaid
PA143617Medicare PIN