Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | Y76242 | UT |
NPI | 1003977620 |
---|---|
Provider Name | Rdean Clark |
First Address | Orem, UT 84058 |
Second Address | Orem, UT 84058 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2006 |
Last Update Date | 08/07/2007 |