MEDICARE: MARK CLAYTON D.M.D.

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	DD3466	NM

General Provider Information

NPI Number	:	1992083596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK CLAYTON D.M.D.

Provider Business Mailing Address
First Line	:	5308 4TH ST NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-5206
Country	:	US
Telephone Number	:	505-341-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	5308 4TH ST NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-5206
Country	:	US
Telephone Number	:	505-341-2273
Fax Number	:

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

Provider Enumeration Date	:	07/30/2011
Last Update Date	:	07/30/2011

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