MEDICARE: DR. CLARK RICHARD ELKINS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D3922	ID

General Provider Information

NPI Number	:	1386627222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLARK RICHARD ELKINS DMD

Provider Business Mailing Address
First Line	:	1110 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 S WASHINGTON AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617
Country	:	US
Telephone Number	:	208-963-0055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	11/18/2011

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