Provider Demographics
NPI:1033277470
Name:CLARKE, JEFF F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:F
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 20TH ST
Mailing Address - Street 2:P.O.417
Mailing Address - City:CENTRAL CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68826-2002
Mailing Address - Country:US
Mailing Address - Phone:308-946-5255
Mailing Address - Fax:308-946-2833
Practice Address - Street 1:1618 20TH ST
Practice Address - Street 2:P.O.417
Practice Address - City:CENTRAL CITY
Practice Address - State:NE
Practice Address - Zip Code:68826-2002
Practice Address - Country:US
Practice Address - Phone:308-946-5255
Practice Address - Fax:308-946-2833
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065395OtherTAX ID. #
NE4706539500Medicaid