Provider Demographics
NPI:1437173697
Name:CLARK, BENNIE JR (DMD)
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5475 SOUTEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219
Mailing Address - Country:US
Mailing Address - Phone:904-764-4576
Mailing Address - Fax:904-766-7021
Practice Address - Street 1:5475 SOUTEL DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219
Practice Address - Country:US
Practice Address - Phone:904-764-4576
Practice Address - Fax:904-766-7021
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN141371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice