NPIMap

Organization Active NPI

Bennie Clark Jr DMD PA

  • Dentist
  • Jacksonville, FL
National Provider Identifier
1295023752
Registry record updated Nov 1, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
BENNIE CLARK JR DMD PA
Practice address
5475 Soutel Dr
Jacksonville, FL 32219-3464
Phone
(904) 764-4576
Fax
(904) 722-9900
NPI assigned
Jul 19, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 1, 2019

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

Authorized official

Name
Dr. Lorraine Polite Clark, DMDNPI 1467475129
Title
Vice President
Phone
(904) 722-2200

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 122300000X Primary
Dental HygienistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 124Q00000X

Addresses

Primary practice location

5475 Soutel Dr
Jacksonville, FL 32219-3464

Mailing address

5475 Soutel Dr
Jacksonville, FL 32219-3464
Phone (904) 764-4576

Other identifiers 1

IdentifierTypeStateIssuer
071395300MedicaidFL

Other names 1

  • Soutel Dental Center II Doing business as

National Provider Directory

National Provider Directory

Locations

5475 Soutel Dr
Jacksonville, FL 32219
Phone (904) 764-4576

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1311033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1572566400000",
    "number": "1295023752",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5475 SOUTEL DR",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322193464",
            "telephone_number": "904-764-4576",
            "fax_number": "904-722-2200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5475 SOUTEL DR",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322193464",
            "telephone_number": "904-764-4576",
            "fax_number": "904-722-9900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BENNIE CLARK JR DMD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-19",
        "last_updated": "2019-11-01",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "LORRAINE",
        "authorized_official_middle_name": "POLITE",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "904-722-2200",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "124Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dental Hygienist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "071395300",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Soutel Dental Center II",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 1, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.