Provider Demographics
NPI:1427057157
Name:CLARK, DENNIS WILLARD (DDS)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:WILLARD
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 1:90 MARKET ST
Mailing Address - Street 2:SUITE 80
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2394
Mailing Address - Country:US
Mailing Address - Phone:541-451-1440
Mailing Address - Fax:541-451-1507
Practice Address - Street 1:90 MARKET ST
Practice Address - Street 2:SUITE 80
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2394
Practice Address - Country:US
Practice Address - Phone:541-451-1440
Practice Address - Fax:541-451-1507
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD55071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice