MEDICARE: DR. ALFONSO CLARK DDS

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	DS021889L	PA

General Provider Information

NPI Number	:	1972665826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALFONSO CLARK DDS

Provider Business Mailing Address
First Line	:	1344 66TH AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19126
Country	:	US
Telephone Number	:	215-224-7300
Fax Number	:	215-924-7450

Provider Business Practice Location Address
First Line	:	1344 66TH AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19126
Country	:	US
Telephone Number	:	215-224-7300
Fax Number	:	215-924-7450

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

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/08/2007

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