=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730116112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRE HAUTE ENDODONTICS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 07/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 S 19TH ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-4129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-235-1598
-----------------------------------------------------
Fax | 812-235-1999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 S 19TH ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-4129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-235-1598
-----------------------------------------------------
Fax | 812-235-1999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR PATRICIA H CLARK
-----------------------------------------------------
Name | DR. PATRICIA H CLARK
-----------------------------------------------------
Credential | DDS MSD
-----------------------------------------------------
Telephone | 812-235-1598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------