Provider Demographics
NPI:1912131301
Name:GROVER, CLARK JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:JOSEPH
Last Name:GROVER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PINE CREST DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1300
Mailing Address - Country:US
Mailing Address - Phone:541-963-6625
Mailing Address - Fax:
Practice Address - Street 1:10 PINE CREST DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1300
Practice Address - Country:US
Practice Address - Phone:541-963-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD4225122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist