Glen Thomas Clark, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

24282 Issued in CA

Practice address

925 W 34TH St
Room #151
Los Angeles, CA 90089-0641

Phone

(213) 740-7405

NPI assigned

Jan 10, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Regents of the University of California

  • Public Health Dentistry
  • Los Angeles, CA
  • NPI 1992831655
  NPD (past)
• University of Southern California

  • General Practice Dentistry
  • Los Angeles, CA
  • NPI 1821168113

  Oral and Maxillofacial Pathology

  NPD (past)
• Verdugo Hills Pharmacy Inc

  • Community/Retail Pharmacy
  • Glendale, CA
  • NPI 1144615550
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168387200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1323043200000",
    "number": "1740339233",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "925 W 34TH ST",
            "address_2": "ROOM #151",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900890641",
            "telephone_number": "213-740-7405"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "925 W 34TH ST",
            "address_2": "ROOM #151",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900890641",
            "telephone_number": "213-740-7405"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "GLEN",
        "middle_name": "THOMAS",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-10",
        "last_updated": "2011-12-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0106X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Pathology",
            "state": "CA",
            "license": "24282",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "CA",
            "license": "24282",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "CA",
            "license": "24282",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00182356",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTICAL",
            "identifier": "G100701",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "ZZZ34010A",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTICAL",
            "identifier": "U0100701",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Elisabeth Oliver Clark, PH.D.
• Elizabeth Clark
• Evans Clark
• Felicia Clark
• Florence Arcuri Clark, PHD, OTR L
• Jarron Clark
• Jennifer Makiki Clark, MPH, CHES
• Jesse Lawton Clark, M.D.
• Jillian Lorraine Clark, LMFT
• Kate Frances Clark, LMFT

• All providers in Los Angeles, CA
• Dentist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.