1578542361 NPI number — DR. TYLER LEE CLARK DDS

Table of content: DR. TYLER LEE CLARK DDS (NPI 1578542361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578542361 NPI number — DR. TYLER LEE CLARK DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
TYLER
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578542361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 S GARDEN WAY
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-8176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-686-9750
Provider Business Mailing Address Fax Number:
541-485-5034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 S GARDEN WAY
Provider Second Line Business Practice Location Address:
STE 140
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-8176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-686-9750
Provider Business Practice Location Address Fax Number:
541-485-5034
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  D10177 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500684192 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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