MEDICARE: DR. CHESTER V. CLARK, JR. D.D.S., M.P.H., P.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	1223G0001X	General Practice Dentistry	2228	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	58932	OTHER	AR	ARKANSAS BCBS PROVIDER ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	809875	OTHER	AR	UNITED CONCORDIA PROVIDER

General Provider Information

NPI Number	:	1962574327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. CHESTER V. CLARK, JR. D.D.S., M.P.H., P.C.

Provider Business Mailing Address
First Line	:	PO BOX 154
Second Line	:
City	:	AMITY
State	:	AR
Zip	:	71921-0154
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	:	PRESIDENT
Name	:	DR. CHESTER V CLARK JR.
Credential	:	DDS, MPH
Telephone Number	:	870-342-5265

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	01/25/2012

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