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General NPI Number Information
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NPI Number | 1750508479
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Entity Type | Organization
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Legal Business Name | JOHN S. CLARK, APDC
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 09/28/2010
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Provider Practice Location Address
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Address Line | 411 SECURITY SQ
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City | GULFPORT
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State | MS
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Zip | 39507-1922
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Country | US
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Telephone | 228-896-8355
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Fax |
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Provider Business Mailing Address
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Address Line | 411 SECURITY SQ
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City | GULFPORT
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State | MS
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Zip | 39507-1922
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN S CLARK
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Credential | D.D.S.
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Telephone | 228-896-8355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | OR-050-82
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License Number State | MS
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