Provider Demographics
NPI:1881722049
Name:CLARK, JEFFREY B (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
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 1:5990 SW 28TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-2545
Mailing Address - Country:US
Mailing Address - Phone:785-273-2565
Mailing Address - Fax:785-273-2567
Practice Address - Street 1:5990 SW 28TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-3525
Practice Address - Country:US
Practice Address - Phone:785-273-2565
Practice Address - Fax:785-273-2567
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS600871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116611OtherBLUE CROSS PROVIDER #