Provider Demographics
NPI:1992874010
Name:CLARK, TONY D (DMD)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 MARY ESTHER CUT OFF NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4025
Mailing Address - Country:US
Mailing Address - Phone:850-244-3511
Mailing Address - Fax:850-664-0858
Practice Address - Street 1:526 MARY ESTHER CUT OFF NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4025
Practice Address - Country:US
Practice Address - Phone:850-244-3511
Practice Address - Fax:850-664-0858
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice