Provider Demographics
NPI:1952050924
Name:CLARK, CHAD MICHAEL (DDS, MS, BS)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-0966
Mailing Address - Country:US
Mailing Address - Phone:307-343-5676
Mailing Address - Fax:
Practice Address - Street 1:604 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2214
Practice Address - Country:US
Practice Address - Phone:307-343-5676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WY1606122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program