MEDICARE: DR. BRUCE R CLARK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7028	CO

General Provider Information

NPI Number	:	1043220684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE R CLARK DDS

Provider Business Mailing Address
First Line	:	2550 STOVER ST
Second Line	:	BLDG E-102
City	:	FORT COLLINS
State	:	CO
Zip	:	80525
Country	:	US
Telephone Number	:	970-498-8607
Fax Number	:	970-498-8607

Provider Business Practice Location Address
First Line	:	2550 STOVER ST
Second Line	:	BLDG E-102
City	:	FORT COLLINS
State	:	CO
Zip	:	80525
Country	:	US
Telephone Number	:	970-498-8607
Fax Number	:	970-498-8607

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/08/2007

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