Provider Demographics
NPI:1962668202
Name:CLARK, DAVID ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
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 1:4209 TIETON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3377
Mailing Address - Country:US
Mailing Address - Phone:509-966-2230
Mailing Address - Fax:
Practice Address - Street 1:4209 TIETON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3377
Practice Address - Country:US
Practice Address - Phone:509-966-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600235801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice