MEDICARE: DR. CHESTER VAN CLARK JR. D.D.S., M.P.H.

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	AR2228	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750653127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHESTER VAN CLARK JR. D.D.S., M.P.H.

Provider Business Mailing Address
First Line	:	439 E THOMPSON ST
Second Line	:
City	:	AMITY
State	:	AR
Zip	:	71921-8602
Country	:	US
Telephone Number	:	870-342-5265
Fax Number	:	870-342-6292

Provider Business Practice Location Address
First Line	:	439 E THOMPSON ST
Second Line	:
City	:	AMITY
State	:	AR
Zip	:	71921-8602
Country	:	US
Telephone Number	:	870-342-5265
Fax Number	:	870-342-6292

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

Provider Enumeration Date	:	02/01/2012
Last Update Date	:	02/01/2012

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Directions to “ DR. CHESTER VAN CLARK JR. D.D.S., M.P.H.” Practice Location

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