MEDICARE: CLARK & VANOVERLOOP DDS PLLC

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		MI

General Provider Information

NPI Number	:	1114323664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK & VANOVERLOOP DDS PLLC

Provider Business Mailing Address
First Line	:	1915 GEORGETOWN CENTER DR
Second Line	:	SUITE 101
City	:	JENISON
State	:	MI
Zip	:	49428-7121
Country	:	US
Telephone Number	:	616-457-6800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1915 GEORGETOWN CENTER DR
Second Line	:	SUITE 101
City	:	JENISON
State	:	MI
Zip	:	49428-7121
Country	:	US
Telephone Number	:	616-457-6800
Fax Number	:

Authorized Official
Title or Position	:	DENTIST / MEMBER
Name	:	DR. AARON SAMUEL CLARK
Credential	:	DDS
Telephone Number	:	616-457-6800

Provider Enumeration Date	:	11/11/2014
Last Update Date	:	10/21/2020

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