Dr. Glen Thomas Clark
Dentist Oral and Maxillofacial Surgeon Oral and Maxillofacial Pathology
925 W 34th St Room #151
Los Angeles
, California 90089-0641
Dr. Glen Thomas Clark
Dentist Oral and Maxillofacial Surgeon Oral and Maxillofacial Pathology
925 W 34th St Room #151
Los Angeles
, California 90089-0641
(213) 740-7405
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About
Features
Specialties
- Dentist
- Oral and Maxillofacial Pathology
- Oral and Maxillofacial Surgeon
Languages spoken
- English
Location
First Address
- Dr. Glen Thomas Clark
- 925 W 34th St Room #151
- Los Angeles, CA
- Zip : 90089-0641
- Phone : (213) 740-7405
Second Address
- Dr. Glen Thomas Clark
- 925 W 34th St Room #151
- Los Angeles, CA
- Zip : 90089-0641
- Phone : (213) 740-7405
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Scope of Practice
| Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
|---|---|---|---|---|
| Y | 122300000X | Dentist | 24282 | CA |
| N | 1223P0106X | Oral and Maxillofacial Pathology | 24282 | CA |
| N | 1223S0112X | Oral and Maxillofacial Surgeon | 24282 | CA |
National Provider Identifier
| NPI | 1740339233 |
|---|---|
| Provider Name | Dr. Glen Thomas Clark |
| First Address | Los Angeles, CA 90089-0641 |
| Second Address | Los Angeles, CA 90089-0641 |
| Gender | M |
| NPI Entity type | Individual |
| Is Sole Proprietor | No |
| Is Organization Subpart | N/A |
| Enumeration Date | 10/01/2007 |
| Last Update Date | 05/12/2011 |
Additional Identifiers
| IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
|---|---|---|
| G100701 | DENTICAL (01) | CA |
| P00182356 | RAILROAD MEDICARE (01) | CA |
| U0100701 | DENTICAL (01) | CA |
| U28629 | (02) | |
| ZZZ34010A | BLUE CROSS BLUE SHIELD (01) | CA |
NPI Footnotes
What is the National Provider Identifier (NPI)
Provider Location Address
Provider Mailing Address
Entity Type Code
1= Person: individual human being who furnishes health care;
2= Non-person: entity other than an individual human being that furnishes health care (Examples: hospital, SNF, hospital subunit, pharmacy, or HMO)
What is a Subpart?
Provider Other Organization Name
1 = former name;
2 = professional name;
3 = doinq business as (d/b/ a) name;
4 = former legal business name;
5 = other.