Active NPI
Glenn D Clark, DDS
- General Practice Dentistry
- Dallas, TX
National Provider Identifier
1013925247
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 11163
- Practice address
- 10405 E Northwest Hwy
204
Dallas, TX 75238-4619 - Phone
- (214) 348-7000
- NPI assigned
- Aug 3, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 11163 | TX | Primary |
Addresses
Primary practice location
10405 E Northwest Hwy
204
Dallas, TX 75238-4619
Mailing address
10405 E. Northwest Hwy
204
Dallas, TX 75238-4600
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Jun 16, 2016 through Jun 16, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11163 | TX | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154563200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1462838400000",
"number": "1013925247",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10405 E. NORTHWEST HWY",
"address_2": "204",
"city": "DALLAS",
"state": "TX",
"postal_code": "752384600"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10405 E NORTHWEST HWY",
"address_2": "204",
"city": "DALLAS",
"state": "TX",
"postal_code": "752384619",
"telephone_number": "214-348-7000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "GLENN",
"middle_name": "D",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-03",
"last_updated": "2016-05-10",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "TX",
"license": "11163",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Dallas, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 2016; 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; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.