MEDICARE: DR. STEPHEN W CLARK D.D.S.

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	1223E0200X	Endodontics	20995	CA
2	1223P0300X	Periodontics	20995	CA
3	1223G0001X	General Practice Dentistry	20995	CA

General Provider Information

NPI Number	:	1447311725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN W CLARK D.D.S.

Provider Business Mailing Address
First Line	:	5963 E SPRING ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-3752
Country	:	US
Telephone Number	:	562-421-8401
Fax Number	:	562-421-0523

Provider Business Practice Location Address
First Line	:	5963 E SPRING ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-3752
Country	:	US
Telephone Number	:	562-421-8401
Fax Number	:	562-421-0523

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	09/18/2019

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