Provider Demographics
NPI:1306060249
Name:CLARK, RUSSELL ADELBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ADELBERT
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 1:7825 47TH AVE NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3732
Mailing Address - Country:US
Mailing Address - Phone:360-657-7785
Mailing Address - Fax:360-657-5696
Practice Address - Street 1:7825 47TH AVE NE
Practice Address - Street 2:SUITE C
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3732
Practice Address - Country:US
Practice Address - Phone:360-657-7785
Practice Address - Fax:360-657-5696
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist