Active NPI
Dale Woodall Clark, DMD
- Dentist
- Russellville, KY
National Provider Identifier
1144339177
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 5933
- Practice address
- 204 East Fourth St
Russellville, KY 42276 - Phone
- (270) 726-7511
- Fax
- (270) 726-6831
- NPI assigned
- Aug 30, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Dentist | 122300000X | 5933 | KY | Primary |
Addresses
Primary practice location
204 East Fourth St
Russellville, KY 42276
Mailing address
204 East Fourth St
Russellville, KY 42276
Phone (270) 726-7511
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 60059334 | Medicaid | KY |
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 Feb 1, 2016 through Feb 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5933 | KY | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156896000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1144339177",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "204 EAST FOURTH ST",
"city": "RUSSELLVILLE",
"state": "KY",
"postal_code": "42276",
"telephone_number": "270-726-7511",
"fax_number": "270-726-6831"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "204 EAST FOURTH ST",
"city": "RUSSELLVILLE",
"state": "KY",
"postal_code": "42276",
"telephone_number": "270-726-7511",
"fax_number": "270-726-6831"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "DALE",
"middle_name": "WOODALL",
"name_prefix": "Mr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-30",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "KY",
"license": "5933",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "60059334",
"state": "KY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Russellville, KY
- Lee Ann Byrd, BHS
- Trisha Kelly Campbell, APRN
- Ashlyn Carey
- Sydney Caron
- Brianna Hope Cerrato
- Clarksville Limb & Brace & Rehab., Inc. (Russellville Orthotics & Prosthetics)
- Commonwealth Health Corporation, Inc. (Med Center Health Logan Orthopaedics)
- Community Health Centers of Western Kentucky Inc
- Kristen Rebecca Cooper, FNP-C
- Melissa D Corbin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; 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.