MEDICARE: DR. GLEN THOMAS CLARK 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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	24282	CA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	24282	CA
3	122300000X	Dentist	24282	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00182356	OTHER	CA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	G100701	OTHER	CA	DENTICAL
3	ZZZ34010A	OTHER	CA	BLUE CROSS BLUE SHIELD
4	U0100701	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1740339233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN THOMAS CLARK DDS

Provider Business Mailing Address
First Line	:	925 W 34TH ST
Second Line	:	ROOM #151
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0641
Country	:	US
Telephone Number	:	213-740-7405
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 W 34TH ST
Second Line	:	ROOM #151
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0641
Country	:	US
Telephone Number	:	213-740-7405
Fax Number	:

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	12/05/2011

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Directions to “ DR. GLEN THOMAS CLARK DDS” Practice Location

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