Provider Demographics
NPI:1053568477
Name:CLARK FAMILY DENTISTRY
Entity type:Organization
Organization Name:CLARK FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-232-1444
Mailing Address - Street 1:1331 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2457
Mailing Address - Country:US
Mailing Address - Phone:816-232-1444
Mailing Address - Fax:816-279-1450
Practice Address - Street 1:1331 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2457
Practice Address - Country:US
Practice Address - Phone:816-232-1444
Practice Address - Fax:816-279-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070143941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty