Provider Demographics
NPI:1548323801
Name:SALK, CLIFFORD T (DDS)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:T
Last Name:SALK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802
Mailing Address - Country:US
Mailing Address - Phone:260-423-2521
Mailing Address - Fax:260-423-6314
Practice Address - Street 1:122 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802
Practice Address - Country:US
Practice Address - Phone:260-423-2521
Practice Address - Fax:260-423-6314
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist