Grace Xinxing Clark, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

12012818A Issued in IN

Practice address

4716 Illinois Rd Ste 101
Fort Wayne, IN 46804-5123

Phone

(260) 432-7970

NPI assigned

Nov 20, 2017

Sex

Female

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 IN

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

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

{
    "created_epoch": "1511136000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1515715200000",
    "number": "1407360910",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5120 BROOKSTONE WAY",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462685417",
            "telephone_number": "812-251-6241"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4716 ILLINOIS RD STE 101",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468045123",
            "telephone_number": "260-432-7970"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "GRACE",
        "middle_name": "XINXING",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-11-20",
        "last_updated": "2018-01-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IN",
            "license": "12012818A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Candace Clark
• David W Clark, M.D.
• Erin D Clark, ATC
• Gabrielle Breann Clark
• Gail A Clark, CNM
• Jack J Clark, D.C.
• Kira Melissa Clark, MS, BCBA
• Lauren Elizabeth Clark
• Mackenzie Marie Clark, MS, LAT, ATC
• McKenzie Clark

• General Practice Dentistry in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• General Practice Dentistry in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 12, 2018; 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.