Provider Demographics
NPI:1568956621
Name:CLARK, JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:CLARK
Suffix:
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 1:203 S CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1225
Mailing Address - Country:US
Mailing Address - Phone:270-338-0606
Mailing Address - Fax:270-338-0617
Practice Address - Street 1:203 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1225
Practice Address - Country:US
Practice Address - Phone:270-338-0606
Practice Address - Fax:270-338-0617
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice