MEDICARE: DR. MIKE L. CLARK FAMILY DENTISTRY

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	261QD0000X	Dental Clinic/Center	DE00010004	WA

General Provider Information

NPI Number	:	1760655005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. MIKE L. CLARK FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	1012 S 40TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98908-3804
Country	:	US
Telephone Number	:	509-575-0419
Fax Number	:	509-966-6595

Provider Business Practice Location Address
First Line	:	1012 S 40TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98908-3804
Country	:	US
Telephone Number	:	509-575-0419
Fax Number	:	509-966-6595

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. BETSY M WARD
Credential	:
Telephone Number	:	509-575-0419

Provider Enumeration Date	:	04/08/2008
Last Update Date	:	04/08/2008

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