Provider Demographics
NPI:1952381840
Name:CLARK, THOMAS R (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
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 1:3410 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5267
Mailing Address - Country:US
Mailing Address - Phone:765-747-9545
Mailing Address - Fax:765-747-0727
Practice Address - Street 1:3410 W PURDUE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5267
Practice Address - Country:US
Practice Address - Phone:765-747-9545
Practice Address - Fax:765-747-0727
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120078451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice