Healthcare Provider Details

I. General information

NPI: 1891896148
Provider Name (Legal Business Name): CLARK FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 LOTUS DR N
MANDEVILLE LA
70471
US

IV. Provider business mailing address

639 LOTUS DR N
MANDEVILLE LA
70471
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-5449
  • Fax: 985-674-0393
Mailing address:
  • Phone: 985-624-5449
  • Fax: 985-674-0393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberLA4476
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL A CLARK
Title or Position: VP
Credential: DDS
Phone: 985-624-5449