MEDICARE: DR. DAKOTA B CLARK DMD

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	6493	AL

General Provider Information

NPI Number	:	1417449349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAKOTA B CLARK DMD

Provider Business Mailing Address
First Line	:	1450 1ST AVE SW
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3329
Country	:	US
Telephone Number	:	256-435-2007
Fax Number	:	256-435-4669

Provider Business Practice Location Address
First Line	:	1450 1ST AVE SW
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3329
Country	:	US
Telephone Number	:	256-435-2007
Fax Number	:	256-435-4669

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

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	10/15/2020

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