Provider Demographics
NPI:1053617308
Name:DAVID A CLARK DDS PLLC
Entity type:Organization
Organization Name:DAVID A CLARK DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-966-2233
Mailing Address - Street 1:4209 TIETON DR STE 102
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3377
Mailing Address - Country:US
Mailing Address - Phone:509-966-2230
Mailing Address - Fax:509-966-8812
Practice Address - Street 1:4209 TIETON DR STE 102
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3377
Practice Address - Country:US
Practice Address - Phone:509-966-2230
Practice Address - Fax:509-966-8812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60023580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124194972Medicaid
WA1962668202Medicaid