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Individual
DR. GLEN THOMAS CLARK
Active
Individual
DR. GLEN THOMAS CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
24282
CA
1223P0106X
Oral and Maxillofacial Pathology Dentistry
24282
CA
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
24282
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
G100701
DENTICAL
CA
01
—
P00182356
RAILROAD MEDICARE
CA
01
—
U0100701
DENTICAL
CA
01
—
ZZZ34010A
BLUE CROSS BLUE SHIELD
CA
Enumeration date
01/10/2007
Last updated
12/05/2011
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