MEDICARE: DENNIS WILLARD CLARK 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	1223G0001X	General Practice Dentistry	D5507	OR

General Provider Information

NPI Number	:	1427057157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS WILLARD CLARK D.D.S.

Provider Business Mailing Address
First Line	:	90 MARKET ST
Second Line	:	SUITE 80
City	:	LEBANON
State	:	OR
Zip	:	97355-2394
Country	:	US
Telephone Number	:	541-451-1440
Fax Number	:	541-451-1507

Provider Business Practice Location Address
First Line	:	90 MARKET ST
Second Line	:	SUITE 80
City	:	LEBANON
State	:	OR
Zip	:	97355-2394
Country	:	US
Telephone Number	:	541-451-1440
Fax Number	:	541-451-1507

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	07/08/2007

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