Provider Demographics
NPI:1972772853
Name:DR. ALBERT CLARK DDS, PC
Entity type:Organization
Organization Name:DR. ALBERT CLARK DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:BAXTER
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-375-1750
Mailing Address - Street 1:1355 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-375-1750
Mailing Address - Fax:801-375-6365
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-375-1750
Practice Address - Fax:801-375-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139191-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty