MEDICARE: DANIEL J. CLARK, DDS, INC.

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	122300000X	Dentist	15180	OH
2	122300000X	Dentist	18843	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	792420	OTHER		UNITED HEALTHCARE

General Provider Information

NPI Number	:	1144228875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANIEL J. CLARK, DDS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 310
Second Line	:
City	:	HILLSBORO
State	:	OH
Zip	:	45133
Country	:	US
Telephone Number	:	937-393-3494
Fax Number	:	937-393-6864

Provider Business Practice Location Address
First Line	:	624 SOUTH HIGH STREET
Second Line	:
City	:	HILLSBORO
State	:	OH
Zip	:	45133
Country	:	US
Telephone Number	:	937-393-3494
Fax Number	:	937-393-6864

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL J. CLARK
Credential	:	D.D.S.
Telephone Number	:	937-393-3494

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	03/15/2010

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