| Doctor Name: | DR. BRENT CLARK |
| NPI Number: | 1174636419 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 7735 |
| Business Practice Address: | Cmr 442 Heidelberg Dental Activity Credentials Office Apo Ae, UT - 09042 |
| Business Phone Number: | 6221172728 |
| Business Fax Number: | |
| Mailing Address: | Cmr 442, Heidelberg Dental Activity Credentials Office APO AE |
| State: | NY |
| Postal Code: | 09042 |
| Phone Number: | 6221172728 |
| Fax Number: | |
| NPI Enumeration Date: | 08/17/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | 7735 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | KY |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |