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General NPI Number Information
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NPI Number | 1992874010
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Entity Type | Individual
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Provider Name | TONY D CLARK D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 526 MARY ESTHER CUT OFF NW
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-4025
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Country | US
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Telephone | 850-244-3511
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Fax | 850-664-0858
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Provider Business Mailing Address
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Address Line | 526 MARY ESTHER CUT OFF NW
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-4025
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Country | US
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Telephone | 850-244-3511
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Fax | 850-664-0858
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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 |
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License Number State | FL
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