Provider Demographics
NPI:1952793051
Name:CLARK, TRACY MANNING (DD S)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:MANNING
Last Name:CLARK
Suffix:
Gender:M
Credentials:DD S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S DAIRY ASHFORD RD
Mailing Address - Street 2:STE. 114
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-3854
Mailing Address - Country:US
Mailing Address - Phone:281-558-3440
Mailing Address - Fax:281-558-3448
Practice Address - Street 1:1500 S DAIRY ASHFORD RD
Practice Address - Street 2:STE. 114
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-3854
Practice Address - Country:US
Practice Address - Phone:281-558-3440
Practice Address - Fax:281-558-3448
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX156031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
760367302OtherDENTAL