Provider Demographics
NPI:1982992574
Name:CLARK, BIANCA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BIANCA
Middle Name:
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 1:692 9TH AVE
Mailing Address - Street 2:APT. 5B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-3667
Mailing Address - Country:US
Mailing Address - Phone:347-317-1814
Mailing Address - Fax:
Practice Address - Street 1:3317 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2801
Practice Address - Country:US
Practice Address - Phone:718-547-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-16
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0554951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice