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General NPI Number Information
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NPI Number | 1649545138
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Entity Type | Organization
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Legal Business Name | CLARK FAMILY DENTISTRY PC
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Dates
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Enumeration Date | 03/15/2012
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Last Update Date | 03/15/2012
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Provider Practice Location Address
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Address Line | 2727 SW 17TH PL
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City | REDMOND
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State | OR
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Zip | 97756-1297
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Country | US
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Telephone | 541-548-3896
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Fax | 541-548-1859
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Provider Business Mailing Address
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Address Line | 2727 SW 17TH PL
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City | REDMOND
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State | OR
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Zip | 97756-1297
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Country | US
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Telephone | 541-548-3896
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Fax | 541-548-1859
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Authorized Official
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Title or Position | OWNER
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Name | DR. EDWARD LEE CLARK
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Credential | DMD
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Telephone | 541-548-3896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D6918
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License Number State | OR
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