=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194861757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK HAMILTON DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 10/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 E COLLEGE AVE
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-321-2714
-----------------------------------------------------
Fax | 850-224-3242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 E COLLEGE AVE
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-321-2714
-----------------------------------------------------
Fax | 850-224-3242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRES
-----------------------------------------------------
Name | DR. JAMES CLARK HAMILTON SR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 850-321-2714
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN3128
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------