Healthcare Provider Details

I. General information

NPI: 1598861445
Provider Name (Legal Business Name): CLARK W MARTINEAU D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3318
US

IV. Provider business mailing address

3032 SADDLEBROOK TRL
POPLAR BLUFF MO
63901-1579
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-4630
  • Fax:
Mailing address:
  • Phone: 573-727-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.022745
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.022745
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: