MEDICARE: HIGH STREET DENTAL DR. JOSHUA CLARK DDS LLC.

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	30022400	OH

General Provider Information

NPI Number	:	1285778712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGH STREET DENTAL DR. JOSHUA CLARK DDS LLC.

Provider Business Mailing Address
First Line	:	3232 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43202-1114
Country	:	US
Telephone Number	:	614-268-4480
Fax Number	:	614-268-4460

Provider Business Practice Location Address
First Line	:	3232 N HIGH ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43202-1114
Country	:	US
Telephone Number	:	614-268-4480
Fax Number	:	614-268-4460

Authorized Official
Title or Position	:	OFFICER
Name	:	DR. JOSHUA ALAN CLARK
Credential	:	DDS
Telephone Number	:	614-268-4460

Provider Enumeration Date	:	02/17/2007
Last Update Date	:	08/22/2020

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