Provider Demographics
NPI:1194800946
Name:CLARK, TIMOTHY PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:PAUL
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:12392 PLEASANT AVE.
Mailing Address - City:BECKER
Mailing Address - State:MN
Mailing Address - Zip Code:55308-0098
Mailing Address - Country:US
Mailing Address - Phone:763-261-5350
Mailing Address - Fax:763-262-5351
Practice Address - Street 1:12392 PLEASANT AVE.
Practice Address - Street 2:
Practice Address - City:BECKER
Practice Address - State:MN
Practice Address - Zip Code:55308-0098
Practice Address - Country:US
Practice Address - Phone:763-261-5350
Practice Address - Fax:763-262-5351
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6B403CLOtherBCBS PROVIDER NUMBER