1710927785 NPI number — DR. EDFORD LEON CLARK JR. DMD

Table of content: GWENDOLYN L WADE FNP-C (NPI 1053894857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710927785 NPI number — DR. EDFORD LEON CLARK JR. DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
EDFORD
Provider Middle Name:
LEON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710927785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 NORTH LAKE DRIVE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
PRESTONSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-886-4260
Provider Business Mailing Address Fax Number:
606-886-0886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 NORTH LAKE DRIVE
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-4260
Provider Business Practice Location Address Fax Number:
606-886-0886
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5490 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5490 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 66083861 . This is a "BCBS OF AL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 322610 . This is a "TIEGEN BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3147483 . This is a "BCBS OF TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 401559 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6005L905 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143184 . This is a "BCBS OF VA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: E914 . This is a "FEDERAL BCBS" identifier . This identifiers is of the category "OTHER".




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