Healthcare Provider Details

I. General information

NPI: 1972101426
Provider Name (Legal Business Name): DAKOTA B CLARK DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 1ST AVE SW
JACKSONVILLE AL
36265-3329
US

IV. Provider business mailing address

1450 1ST AVE SW
JACKSONVILLE AL
36265-3329
US

V. Phone/Fax

Practice location:
  • Phone: 256-435-2007
  • Fax:
Mailing address:
  • Phone: 256-435-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DAKOTA B CLARK
Title or Position: OWNER
Credential: DMD
Phone: 256-435-2007