Provider Demographics
NPI:1306061270
Name:DR HERALD R CLARK
Entity type:Organization
Organization Name:DR HERALD R CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PC
Authorized Official - Phone:801-486-9434
Mailing Address - Street 1:2036 S 1300 E
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3601
Mailing Address - Country:US
Mailing Address - Phone:801-486-9434
Mailing Address - Fax:801-426-9444
Practice Address - Street 1:2036 S 1300 E
Practice Address - Street 2:SUITE B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3601
Practice Address - Country:US
Practice Address - Phone:801-486-9434
Practice Address - Fax:801-426-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty