Provider Demographics
NPI:1306114889
Name:GUY C CLARK
Entity type:Organization
Organization Name:GUY C CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-898-8011
Mailing Address - Street 1:3613 NM HWY 528 SUITE G
Mailing Address - Street 2:
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 NM HWY 528 SUITE G
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty