MEDICARE: W.A. CLARK, D.D.S., P.L.L.C.

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	122300000X	Dentist	6354	OK

General Provider Information

NPI Number	:	1740521509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W.A. CLARK, D.D.S., P.L.L.C.

Provider Business Mailing Address
First Line	:	612 BELLEMEADE ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-1903
Country	:	US
Telephone Number	:	202-271-3096
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 NE 36TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-5002
Country	:	US
Telephone Number	:	405-427-5405
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WALEED AJAMU CLARK
Credential	:	DDS
Telephone Number	:	202-271-3096

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	03/04/2013

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