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General NPI Number Information
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NPI Number | 1710117999
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Entity Type | Organization
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Legal Business Name | TRISCHA A. CLARKE D.D.S., P.L.L.C.
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Dates
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Enumeration Date | 07/22/2009
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Last Update Date | 07/22/2009
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Provider Practice Location Address
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Address Line | 427 STONE WOOD DR
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City | BROKEN ARROW
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State | OK
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Zip | 74012-1026
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Country | US
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Telephone | 918-630-4155
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Fax |
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Provider Business Mailing Address
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Address Line | 427 STONE WOOD DR
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City | BROKEN ARROW
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State | OK
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Zip | 74012-1026
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Country | US
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Telephone | 918-630-4155
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TRISCHA ANN CLARKE
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Credential | D.D.S.
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Telephone | 918-630-4155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 5859
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License Number State | OK
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