Provider Demographics
NPI:1023157153
Name:CLARK, THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
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 1:4402 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77022-2934
Mailing Address - Country:US
Mailing Address - Phone:713-691-1831
Mailing Address - Fax:713-691-3836
Practice Address - Street 1:4402 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-2934
Practice Address - Country:US
Practice Address - Phone:713-691-1831
Practice Address - Fax:713-691-3836
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice