Provider Demographics
NPI:1386778520
Name:CLARK, MICHAEL V (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:V
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:6900 YELLOWTAIL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-6102
Mailing Address - Country:US
Mailing Address - Phone:307-635-9251
Mailing Address - Fax:307-635-9218
Practice Address - Street 1:6900 YELLOWTAIL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6102
Practice Address - Country:US
Practice Address - Phone:307-635-9251
Practice Address - Fax:307-635-9218
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WY11081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119846700Medicaid