Healthcare Provider Details

I. General information

NPI: 1770410235
Provider Name (Legal Business Name): WILLIAM TANNER CLARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 CRAVEN ST BLDG 3230
SAN DIEGO CA
92136-5596
US

IV. Provider business mailing address

643 WOODMONT RD
JONESBOROUGH TN
37659-3764
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-8240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13133
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: