Basic Information
| Provider Information | |||||||||
| NPI: | 1619985884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 E. JOYCE | ||||||||
| Address2: | STE 221 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794431849 | ||||||||
| FaxNumber: | 4794432034 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 E. JOYCE | ||||||||
| Address2: | STE 221 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794431849 | ||||||||
| FaxNumber: | 4794432034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3349 | AR | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 870436704 | 01 | AR | OLD TAX ID # | OTHER | 412175658 | 01 | AR | NEW TAX ID # | OTHER | 143894608 | 05 | AR | MEDICAID |