Active NPI
Alan Douglas Clark, DDS
- General Practice Dentistry
- Fayetteville, AR
National Provider Identifier
1619985884
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 3349
- Practice address
- 745 E. Joyce
Ste 221
Fayetteville, AR 72703 - Phone
- (479) 443-1849
- Fax
- (479) 443-2034
- NPI assigned
- Aug 4, 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 | 3349 | AR | Primary |
Addresses
Primary practice location
745 E. Joyce
Ste 221
Fayetteville, AR 72703
Mailing address
745 E. Joyce
Ste 221
Fayetteville, AR 72703
Phone (479) 443-1849
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 870436704 | Other | AR | OLD TAX ID # |
| 412175658 | Other | AR | NEW TAX ID # |
| 143894608 | Medicaid | AR |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3349 | AR | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Prairie Grove Dental Center PLLC | General Practice | Current | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- General Practice Dentistry
- Prairie Grove, AR
- NPI 1508454612
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154649600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1351209600000",
"number": "1619985884",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "745 E. JOYCE",
"address_2": "STE 221",
"city": "FAYETTEVILLE",
"state": "AR",
"postal_code": "72703",
"telephone_number": "479-443-1849",
"fax_number": "479-443-2034"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "745 E. JOYCE",
"address_2": "STE 221",
"city": "FAYETTEVILLE",
"state": "AR",
"postal_code": "72703",
"telephone_number": "479-443-1849",
"fax_number": "479-443-2034"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "ALAN",
"middle_name": "DOUGLAS",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-04",
"last_updated": "2012-10-26",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "AR",
"license": "3349",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "OLD TAX ID #",
"identifier": "870436704",
"state": "AR"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NEW TAX ID #",
"identifier": "412175658",
"state": "AR"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "143894608",
"state": "AR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fayetteville, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.