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General NPI Number Information
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NPI Number | 1972772853
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Entity Type | Organization
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Legal Business Name | DR. ALBERT CLARK DDS, PC
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Dates
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Enumeration Date | 02/26/2008
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 1355 N UNIVERSITY AVE SUITE 320
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City | PROVO
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State | UT
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Zip | 84604-2721
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Country | US
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Telephone | 801-375-1750
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Fax | 801-375-6365
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Provider Business Mailing Address
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Address Line | 1355 N UNIVERSITY AVE SUITE 320
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City | PROVO
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State | UT
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Zip | 84604-2721
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Country | US
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Telephone | 801-375-1750
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Fax | 801-375-6365
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALBERT BAXTER CLARK
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Credential | DDS
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Telephone | 801-375-1750
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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 | 139191-9922
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License Number State | UT
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