Healthcare Provider Details

I. General information

NPI: 1336508092
Provider Name (Legal Business Name): PATRICK J CLARK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2016
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7603 NORTH AVE
RIVER FOREST IL
60305-1133
US

IV. Provider business mailing address

548 SHERIDAN RD APT 2N
EVANSTON IL
60202-4719
US

V. Phone/Fax

Practice location:
  • Phone: 708-456-7787
  • Fax:
Mailing address:
  • Phone: 253-241-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number019.032040
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: