Provider Demographics
NPI:1699904003
Name:CLARK, BRIDGETE H (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIDGETE
Middle Name:H
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:PO BOX 1406
Mailing Address - Street 2:
Mailing Address - City:CASTROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95012-1406
Mailing Address - Country:US
Mailing Address - Phone:831-479-6472
Mailing Address - Fax:831-477-5687
Practice Address - Street 1:6500 SOQUEL DRIVE
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003
Practice Address - Country:US
Practice Address - Phone:831-479-6472
Practice Address - Fax:831-477-5687
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42987122300000X
WI4771-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist