MEDICARE: TONYA ELAINE CLARK RDHAP

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	124Q00000X	Dental Hygienist	23	CA

General Provider Information

NPI Number	:	1891777207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONYA ELAINE CLARK RDHAP

Provider Business Mailing Address
First Line	:	1786 BANNON CREEK DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95833-1518
Country	:	US
Telephone Number	:	916-283-5622
Fax Number	:	916-283-5622

Provider Business Practice Location Address
First Line	:	1786 BANNON CREEK DR
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95833-1518
Country	:	US
Telephone Number	:	916-952-5620
Fax Number	:	916-283-5622

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

Provider Enumeration Date	:	11/19/2005
Last Update Date	:	07/08/2007

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