Provider Demographics
NPI:1710927785
Name:CLARK, EDFORD LEON JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDFORD
Middle Name:LEON
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 1:415 NORTH LAKE DRIVE
Mailing Address - Street 2:STE 201
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653
Mailing Address - Country:US
Mailing Address - Phone:606-886-4260
Mailing Address - Fax:606-886-0886
Practice Address - Street 1:415 NORTH LAKE DRIVE
Practice Address - Street 2:STE 201
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653
Practice Address - Country:US
Practice Address - Phone:606-886-4260
Practice Address - Fax:606-886-0886
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5490122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
66083861OtherBCBS OF AL
322610OtherTIEGEN BCBS
3147483OtherBCBS OF TN
401559OtherUNITED CONCORDIA
KY6005L905Medicaid
VA143184OtherBCBS OF VA
E914OtherFEDERAL BCBS