Provider Demographics
NPI:1720118359
Name:CLARK, RAYMOND B (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:B
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 1:1520 HORTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5127
Mailing Address - Country:US
Mailing Address - Phone:517-784-2061
Mailing Address - Fax:517-784-2115
Practice Address - Street 1:1520 HORTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-5127
Practice Address - Country:US
Practice Address - Phone:517-784-2061
Practice Address - Fax:517-784-2115
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0167241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice