Healthcare Provider Details

I. General information

NPI: 1679565402
Provider Name (Legal Business Name): BENJAMIN R CLARKE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-2600
  • Fax:
Mailing address:
  • Phone: 702-653-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number21488
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: