MEDICARE: BRUCE RICHARD CLARKE D.D.S.

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	029797	NY

General Provider Information

NPI Number	:	1407095383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE RICHARD CLARKE D.D.S.

Provider Business Mailing Address
First Line	:	203 NORTH SECOND AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118
Country	:	US
Telephone Number	:	518-664-7348
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 NORTH SECOND AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118
Country	:	US
Telephone Number	:	518-664-7348
Fax Number	:

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

Provider Enumeration Date	:	02/17/2009
Last Update Date	:	02/17/2009

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