=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891857280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARK ANDREW MARTIN SR. DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 N BEDFORD DR STE 215
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-278-5403
-----------------------------------------------------
Fax | 310-278-0850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 N BEDFORD DR STE 215
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 29362
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------