Provider Demographics
NPI:1215669239
Name:CLARK, RACHEL C (DDS)
Entity type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WISCONSIN AVE # 35
Mailing Address - Street 2:
Mailing Address - City:CENTURIA
Mailing Address - State:WI
Mailing Address - Zip Code:54824-9042
Mailing Address - Country:US
Mailing Address - Phone:715-646-2161
Mailing Address - Fax:
Practice Address - Street 1:601 WISCONSIN AVE # 35
Practice Address - Street 2:
Practice Address - City:CENTURIA
Practice Address - State:WI
Practice Address - Zip Code:54824-9042
Practice Address - Country:US
Practice Address - Phone:715-646-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001022-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist