Provider Demographics
NPI:1215948286
Name:CLARK, GUY CHARLES (DDS PA)
Entity type:Individual
Prefix:DR
First Name:GUY
Middle Name:CHARLES
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 NEW MEXICO HIGHWAY 528
Mailing Address - Street 2:SUITE G
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-898-8011
Mailing Address - Fax:505-890-7423
Practice Address - Street 1:3613 NEW MEXICO HIGHWAY 528
Practice Address - Street 2:SUITE G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114
Practice Address - Country:US
Practice Address - Phone:505-898-8011
Practice Address - Fax:505-890-7423
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD11391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
141339OtherUNITED CONCORDIA INSURANC