Shane Thomas Clark, DMD

Primary specialty

EndodonticsTaxonomy code 1223E0200X

License

DD4100 Issued in NM

Practice address

2800 Coors Blvd NW
Albuquerque, NM 87120-1204

Phone

(505) 352-1166

NPI assigned

Jun 16, 2014

Last updated

Sep 26, 2015By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NM

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Networks

• TX HMO D-SNP
• CO HMO D-SNP
• NM HMO C-SNP

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Albuquerque Modern Dentistry, LLC

  dba Albuquerque Modern Dentistry

  • General Practice Dentistry
  • Albuquerque, NM
  • NPI 1487953790
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402876800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1443225600000",
    "number": "1003220203",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8400 OAKLAND AVE NE",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871222721",
            "telephone_number": "512-689-8382"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2800 COORS BLVD NW",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871201204",
            "telephone_number": "505-352-1166"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "SHANE",
        "middle_name": "THOMAS",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-06-16",
        "last_updated": "2015-09-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223E0200X",
            "taxonomy_group": "",
            "desc": "Dentist, Endodontics",
            "state": "NM",
            "license": "DD4100",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Rebecca Jand Clark, LPCC, CRC
• Richard Travis Clark, M.D.
• Ross Clark, MD
• Sabrina Clark
• Serina Clark
• Sonja Dana Clark, PSYD, LPCC
• Tarron James Clark, LAT, ATC
• Teresa Watkins Clark, LPCC
• Trevor Clark, D.C.
• Veralyn Elizabeth Clark

• Endodontics in Albuquerque, NM
• Providers in Albuquerque, NM by specialty
• Endodontics in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.