Healthcare Provider Details

I. General information

NPI: 1891857280
Provider Name (Legal Business Name): CLARK ANDREW MARTIN SR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N BEDFORD DR STE 215
BEVERLY HILLS CA
90210
US

IV. Provider business mailing address

435 N BEDFORD DR STE 215
BEVERLY HILLS CA
90210
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-5403
  • Fax: 310-278-0850
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number29362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: