MEDICARE: DR. TANNER MARK 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	DS038910	PA

General Provider Information

NPI Number	:	1679841811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANNER MARK CLARK D.M.D.

Provider Business Mailing Address
First Line	:	2203 FITZWATER ST UNIT 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1132
Country	:	US
Telephone Number	:	208-317-8555
Fax Number	:

Provider Business Practice Location Address
First Line	:	2203 FITZWATER ST UNIT 1
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1132
Country	:	US
Telephone Number	:	208-317-8555
Fax Number	:

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

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	04/25/2016

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