Provider Demographics
NPI:1801528336
Name:CLARK, REBECCA LEANN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7865B ESTRADA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-2321
Mailing Address - Country:US
Mailing Address - Phone:972-765-5186
Mailing Address - Fax:
Practice Address - Street 1:2030 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELIZAETTHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:270-763-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist