Provider Demographics
NPI:1740339233
Name:CLARK, GLEN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:THOMAS
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 1:925 W 34TH ST
Mailing Address - Street 2:ROOM #151
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0641
Mailing Address - Country:US
Mailing Address - Phone:213-740-7405
Mailing Address - Fax:
Practice Address - Street 1:925 W 34TH ST
Practice Address - Street 2:ROOM #151
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0641
Practice Address - Country:US
Practice Address - Phone:213-740-7405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA242821223P0106X, 1223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00182356OtherRAILROAD MEDICARE
CAG100701OtherDENTICAL
CAZZZ34010AOtherBLUE CROSS BLUE SHIELD
CAU0100701OtherDENTICAL
CAP00182356OtherRAILROAD MEDICARE
CAZZZ34010AOtherBLUE CROSS BLUE SHIELD