Provider Demographics
NPI:1649261850
Name:CLARK, JEFFREY M (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
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 1:1802 ROCKINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3348
Mailing Address - Country:US
Mailing Address - Phone:270-783-0064
Mailing Address - Fax:270-901-1997
Practice Address - Street 1:1802 ROCKINGHAM AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3348
Practice Address - Country:US
Practice Address - Phone:270-783-0064
Practice Address - Fax:270-901-1997
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY89601223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3146210OtherBCBS TN
132568OtherTRICARE
TN702005606OtherCARITEN COMMERICAL INSURA
TN3226722Medicare ID - Type Unspecified
U80611Medicare UPIN