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General NPI Number Information
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NPI Number | 1407995426
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Entity Type | Individual
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Provider Name | JEFFREY CLARK DMD
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Gender | Male
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 902 S 6TH ST
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51501-6441
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Country | US
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Telephone | 712-325-1990
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Fax |
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Provider Business Mailing Address
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Address Line | 902 S 6TH ST
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51501-6441
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Country | US
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Telephone | 712-325-1990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 12-2006
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License Number State | NM
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