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General NPI Number Information
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NPI Number | 1053568477
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Entity Type | Organization
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Legal Business Name | CLARK FAMILY DENTISTRY
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Dates
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Enumeration Date | 08/27/2008
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Last Update Date | 08/27/2008
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Provider Practice Location Address
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Address Line | 1331 VILLAGE DR
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City | SAINT JOSEPH
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State | MO
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Zip | 64506-2457
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Country | US
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Telephone | 816-232-1444
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Fax | 816-279-1450
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Provider Business Mailing Address
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Address Line | 1331 VILLAGE DR
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City | SAINT JOSEPH
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State | MO
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Zip | 64506-2457
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Country | US
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Telephone | 816-232-1444
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Fax | 816-279-1450
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. HEATHER ELISE CLARK
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Credential | DDS
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Telephone | 816-232-1444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2007014394
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License Number State | MO
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