Provider Demographics
NPI:1336162569
Name:CLARK, GERALD L (DDS)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
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:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-0207
Mailing Address - Country:US
Mailing Address - Phone:972-775-2377
Mailing Address - Fax:
Practice Address - Street 1:103 S 7TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-3211
Practice Address - Country:US
Practice Address - Phone:972-775-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice