Provider Demographics
NPI:1316063662
Name:CLARK, EVELYN L (DDS)
Entity type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6724 TROOST AVE
Mailing Address - Street 2:SUITE 407
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1500
Mailing Address - Country:US
Mailing Address - Phone:816-523-1414
Mailing Address - Fax:816-523-2123
Practice Address - Street 1:6724 TROOST AVE
Practice Address - Street 2:SUITE 407
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1500
Practice Address - Country:US
Practice Address - Phone:816-523-1414
Practice Address - Fax:816-523-2123
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO150001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice