MEDICARE: DR. STAN REED CLARK D.M.D

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	5428628-9921	UT

General Provider Information

NPI Number	:	1629021969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STAN REED CLARK D.M.D

Provider Business Mailing Address
First Line	:	160 S 1000 E
Second Line	:	SUITE 340
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1428
Country	:	US
Telephone Number	:	801-355-3065
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 S 1000 E
Second Line	:	SUITE 340
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1428
Country	:	US
Telephone Number	:	801-355-3065
Fax Number	:

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	02/27/2008

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