Provider Demographics
NPI:1649347097
Name:CLARK, RANDOLPH LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:301 S BOULEVARD ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3878
Mailing Address - Country:US
Mailing Address - Phone:405-348-9182
Mailing Address - Fax:405-330-1677
Practice Address - Street 1:301 S BOULEVARD ST
Practice Address - Street 2:SUITE 118
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3878
Practice Address - Country:US
Practice Address - Phone:405-348-9182
Practice Address - Fax:405-330-1677
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKOK49921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK73-137-9303OtherFEDERAL TAX I.D