Provider Demographics
NPI:1295023752
Name:BENNIE CLARK JR DMD PA
Entity Type:Organization
Organization Name:BENNIE CLARK JR DMD PA
Other - Org Name:SOUTEL DENTAL CENTER II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:POLITE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-722-2200
Mailing Address - Street 1:5475 SOUTEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-3464
Mailing Address - Country:US
Mailing Address - Phone:904-764-4576
Mailing Address - Fax:904-722-2200
Practice Address - Street 1:5475 SOUTEL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-3464
Practice Address - Country:US
Practice Address - Phone:904-764-4576
Practice Address - Fax:904-722-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071395300Medicaid