MEDICARE: PAT 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	261QD0000X	Dental Clinic/Center	DS0000007499	TN

General Provider Information

NPI Number	:	1316958473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAT CLARK DDS

Provider Business Mailing Address
First Line	:	6750 POPLAR AVE
Second Line	:	SUITE 700
City	:	MEMPHIS
State	:	TN
Zip	:	38138-7438
Country	:	US
Telephone Number	:	901-309-3045
Fax Number	:	901-309-3065

Provider Business Practice Location Address
First Line	:	6750 POPLAR AVE
Second Line	:	SUITE 700
City	:	MEMPHIS
State	:	TN
Zip	:	38138-7438
Country	:	US
Telephone Number	:	901-309-3045
Fax Number	:	901-309-3065

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAT CLARK
Credential	:	DDS
Telephone Number	:	901-309-3045

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	08/22/2020

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