Provider Demographics
NPI:1376557736
Name:CLARK, JAMES A (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 LAKE OTIS PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5207
Mailing Address - Country:US
Mailing Address - Phone:907-561-1430
Mailing Address - Fax:907-561-2697
Practice Address - Street 1:3650 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5207
Practice Address - Country:US
Practice Address - Phone:907-561-1430
Practice Address - Fax:907-561-2697
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0389Medicaid
AK831476OtherTRI-CARE ID
AKDD0389Medicaid