Healthcare Provider Details

I. General information

NPI: 1558857680
Provider Name (Legal Business Name): CLARK JARED PLOST DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2018
Last Update Date: 07/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

321 N OKLAHOMA AVE APT 508
OKLAHOMA CITY OK
73104-1848
US

V. Phone/Fax

Practice location:
  • Phone: 918-808-8548
  • Fax:
Mailing address:
  • Phone: 918-808-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7064
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: