MEDICARE: DR. SHANNON CAROL 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	122300000X	Dentist	2020005163	MO
2	122300000X	Dentist	62065	KS
3	122300000X	Dentist	3142	AR

General Provider Information

NPI Number	:	1922273481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON CAROL CLARK DDS

Provider Business Mailing Address
First Line	:	1411 S RANGE LINE RD
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64801-5589
Country	:	US
Telephone Number	:	417-541-2666
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 S RANGE LINE RD
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64801-5589
Country	:	US
Telephone Number	:	417-541-2666
Fax Number	:

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

Provider Enumeration Date	:	04/25/2008
Last Update Date	:	03/18/2026

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