Provider Demographics
NPI:1215962394
Name:CLARK, ROBERT S (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 LARKIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3278
Mailing Address - Country:US
Mailing Address - Phone:859-278-9376
Mailing Address - Fax:859-276-0260
Practice Address - Street 1:2533 LARKIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3278
Practice Address - Country:US
Practice Address - Phone:859-278-9376
Practice Address - Fax:859-276-0260
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66241223S0112X, 204E00000X, 204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64066244Medicaid
KY60066248Medicaid