Provider Demographics
NPI:1679745129
Name:CLARK III, HARRY M
Entity type:Individual
Prefix:MR
First Name:HARRY
Middle Name:M
Last Name:CLARK III
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 COUNTY ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:NY
Mailing Address - Zip Code:12834-6302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:519 STATE ROUTE 67
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4334
Practice Address - Country:US
Practice Address - Phone:518-899-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist