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General NPI Number Information
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NPI Number | 1013925247
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Entity Type | Individual
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Provider Name | GLENN D CLARK DDS
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Gender | Male
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 05/10/2016
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Provider Practice Location Address
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Address Line | 10405 E NORTHWEST HWY 204
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City | DALLAS
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State | TX
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Zip | 75238-4619
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Country | US
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Telephone | 214-348-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 10405 E. NORTHWEST HWY 204
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City | DALLAS
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State | TX
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Zip | 75238-4600
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 11163
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License Number State | TX
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