Larry Clark
Individual provider Active NPI General Practice Dentistry · Boscobel, WI
NPI 1174945919 · NPPES record last updated Jan 14, 2014
Key facts
- NPI
- 1174945919
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 5001678 (WI)
- Practice address
- 105 E Bluff St
Boscobel, WI 53805-1610 - Phone
- (608) 375-4549
- NPI assigned
- Jan 14, 2014
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160114001836 | WI | Order and Referring Only - Oral Surgery |
0446553077 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5001678 | WI | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 5001678 | WI | Yes |
Addresses
Primary practice location
105 E Bluff St
Boscobel, WI 53805-1610
Mailing address
105 E Bluff St
Boscobel, WI 53805-1610
Phone (608) 375-4549
Other providers in Boscobel, WI
- Kaitlin Bushee
- Lora Lea Byers
- Brandii Cabrera
- Gerard Ceulemans
- Thomas Andrew Chweh
- Allyson Cooley
- Burton Dale Cox Jr.
- Jonathan R Demory
- Barbara L Dewitt
- Dr Michael S Mecikalski SC
All providers in Boscobel, WI · General Practice Dentistry in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 14, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.