Basic Information
| Provider Information | |||||||||
| NPI: | 1033259908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 LINCOLN ST | ||||||||
| Address2: | MED STAFF SVCS | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083348015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 281 LINCOLN ST | ||||||||
| Address2: | MED STAFF SVCS | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083348015 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 21633 | MA | Y | Dental Providers | Dentist |
No ID Information.