Provider Demographics
NPI:1992336127
Name:DEVIN CLARK, DDS, PLLC
Entity type:Organization
Organization Name:DEVIN CLARK, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-808-3375
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-0399
Mailing Address - Country:US
Mailing Address - Phone:360-785-4755
Mailing Address - Fax:360-785-3336
Practice Address - Street 1:617 CEMETERY RD STE A
Practice Address - Street 2:
Practice Address - City:WINLOCK
Practice Address - State:WA
Practice Address - Zip Code:98596-9303
Practice Address - Country:US
Practice Address - Phone:360-785-4655
Practice Address - Fax:360-785-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty