Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 12008231A | IN |
NPI | 1013018803 |
---|---|
Provider Name | Dr. David Bryce Clark |
First Address | Shelbyville, IN 46176-2949 |
Second Address | Shelbyville, IN 46176-2949 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2006 |
Last Update Date | 08/07/2007 |