Healthcare Provider Details

I. General information

NPI: 1720202203
Provider Name (Legal Business Name): CLARK REGAN SWEENEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233-2186
US

IV. Provider business mailing address

PO BOX 1881
MILWAUKEE WI
53201-1881
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-6212
  • Fax: 414-288-8361
Mailing address:
  • Phone: 414-288-6212
  • Fax: 414-288-8361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5001864
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: