MEDICARE: CLEAR CREEK DENTISTRY, PLLC

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	27909	TX

General Provider Information

NPI Number	:	1659738276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEAR CREEK DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	5430 PINE SPRINGS CT
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-4052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 NORMAL PARK DR STE 202
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77320-3770
Country	:	US
Telephone Number	:	617-319-6674
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY CLARK
Credential	:	D.M.D.
Telephone Number	:	936-291-0032

Provider Enumeration Date	:	01/27/2016
Last Update Date	:	07/05/2016

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