Provider Demographics
NPI:1316133093
Name:CLARK, STEPHEN JAY (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAY
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8228 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415
Mailing Address - Country:US
Mailing Address - Phone:937-454-1103
Mailing Address - Fax:937-454-1140
Practice Address - Street 1:8228 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1641
Practice Address - Country:US
Practice Address - Phone:937-454-1103
Practice Address - Fax:937-454-1140
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188861223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics