MEDICARE: KELLY R CLARKE DDS

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	1223G0001X	General Practice Dentistry	D8421	OR
2	1223G0001X	General Practice Dentistry	DE00010199	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437132305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY R CLARKE DDS

Provider Business Mailing Address
First Line	:	2204 E 29TH AVE
Second Line	:	STE. 208
City	:	SPOKANE
State	:	WA
Zip	:	99203-3961
Country	:	US
Telephone Number	:	509-535-9515
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 E 29TH AVE
Second Line	:	STE. 208
City	:	SPOKANE
State	:	WA
Zip	:	99203-3961
Country	:	US
Telephone Number	:	509-535-9515
Fax Number	:

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

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	07/18/2008

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