Basic Information
| Provider Information | |||||||||
| NPI: | 1467931352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2159 BELLA OAKS DR | ||||||||
| Address2: | |||||||||
| City: | TULARE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932747760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594958085 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4129 S MOONEY BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932779147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597321953 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2018 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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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 | 1223G0001X | DDS102890 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DDS102890 | 01 | CA | CALIFORNIA DENTAL LICENSE | OTHER |