Provider Demographics
NPI:1689700684
Name:CLARK, JEFFREY C (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:CLARK
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 1:141 W 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3401
Mailing Address - Country:US
Mailing Address - Phone:505-325-7121
Mailing Address - Fax:505-564-3005
Practice Address - Street 1:141 W 20TH STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3401
Practice Address - Country:US
Practice Address - Phone:505-325-7121
Practice Address - Fax:505-564-3005
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD26741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice