1861452757 NPI number — DR. CLARK MICHAEL COMEAUX D.D.S.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861452757 NPI number — DR. CLARK MICHAEL COMEAUX D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COMEAUX
Provider First Name:
CLARK
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
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:
1861452757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BLDG 38717 38TH STREET,
Provider Second Line Business Mailing Address:
USA DENTAC
Provider Business Mailing Address City Name:
FT GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30905-5660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-787-1070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLDG 38717 38TH STREET,
Provider Second Line Business Practice Location Address:
USA DENTAC,
Provider Business Practice Location Address City Name:
FORT GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30905-5660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-787-1070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2006

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: 1223S0112X , with the licence number:  3666 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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