Provider Demographics
NPI:1811242084
Name:CLARK, KARA ELIZABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:KARA
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 TULIP LN
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3022
Mailing Address - Country:US
Mailing Address - Phone:219-670-4127
Mailing Address - Fax:
Practice Address - Street 1:619 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1645
Practice Address - Country:US
Practice Address - Phone:219-836-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011809A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist