MEDICARE: DR. KYLE WARNER CLARK D.M.D.

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	7023394-8903	UT

General Provider Information

NPI Number	:	1891955662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE WARNER CLARK D.M.D.

Provider Business Mailing Address
First Line	:	1008 RUSHLEIGH RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1415
Country	:	US
Telephone Number	:	801-722-4847
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 RUSHLEIGH RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1415
Country	:	US
Telephone Number	:	801-722-4847
Fax Number	:

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

Provider Enumeration Date	:	06/14/2008
Last Update Date	:	06/14/2008

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