Provider Demographics
NPI:1336596196
Name:CLARK DENTAL STUDIO, PLLC
Entity Type:Organization
Organization Name:CLARK DENTAL STUDIO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:731-431-5613
Mailing Address - Street 1:951 RIVERFRONT PKWY
Mailing Address - Street 2:#303
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:951 RIVERFRONT PKWY
Practice Address - Street 2:#303
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2185
Practice Address - Country:US
Practice Address - Phone:423-266-7927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty