=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346201431
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON DREW CLARK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7810 PROVIDENCE RD SUITE 100
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-2987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-543-3766
-----------------------------------------------------
Fax | 704-543-3768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7810 PROVIDENCE RD SUITE 100
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-2987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-543-3766
-----------------------------------------------------
Fax | 704-543-3768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 6966
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------