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General NPI Number Information
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NPI Number | 1104907617
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Entity Type | Individual
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Provider Name | DORRANCE D CLARK DDS, MSD
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Gender | Male
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 12/18/2025
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Provider Practice Location Address
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Address Line | 2425 E 12 MILE RD
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City | WARREN
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State | MI
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Zip | 48092-5667
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Country | US
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Telephone | 586-519-5977
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Fax |
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Provider Business Mailing Address
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Address Line | 2425 E 12 MILE RD
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City | WARREN
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State | MI
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Zip | 48092-5667
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Country | US
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Telephone | 586-519-5826
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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 | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2901018485
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License Number State | MI
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