MEDICARE: STEPHANIE 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	122300000X	Dentist	104042	CA

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

General Provider Information

NPI Number	:	1336792233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE CLARK DDS

Provider Business Mailing Address
First Line	:	404 E 1ST ST # 197
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-4903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5464 SOUTH ST
Second Line	:	STE A
City	:	LAKEWOOD
State	:	CA
Zip	:	90712
Country	:	US
Telephone Number	:	253-279-3647
Fax Number	:

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

Provider Enumeration Date	:	07/19/2019
Last Update Date	:	07/19/2019

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