Provider Demographics
NPI:1730422106
Name:CLARK, DANIEL DEE (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:DEE
Last Name:CLARK
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 1:4104 N BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2374
Mailing Address - Country:US
Mailing Address - Phone:214-793-7256
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY
Practice Address - Street 2:SUITE D AND E
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-325-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD39041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice