Healthcare Provider Details

I. General information

NPI: 1306114889
Provider Name (Legal Business Name): GUY C CLARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3613 NM HWY 528 SUITE G
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

3613 NM HWY 528 SUITE G
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-8011
  • Fax: 505-890-7423
Mailing address:
  • Phone: 505-898-8011
  • Fax: 505-890-7423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: GUY C CLARK
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-898-8011