Jeffrey M Clark, DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

8960 Issued in KY

Practice address

1802 Rockingham Ave
Bowling Green, KY 42104-3348

Phone

(270) 783-0064

Fax

(270) 901-1997

NPI assigned

Nov 4, 2005

Last updated

Sep 21, 2021By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1131062400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1632182400000",
    "number": "1649261850",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1802 ROCKINGHAM AVE",
            "city": "BOWLING GREEN",
            "state": "KY",
            "postal_code": "421043348",
            "telephone_number": "270-783-0064",
            "fax_number": "270-901-1997"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1802 ROCKINGHAM AVE",
            "city": "BOWLING GREEN",
            "state": "KY",
            "postal_code": "421043348",
            "telephone_number": "270-783-0064",
            "fax_number": "270-901-1997"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JEFFREY",
        "middle_name": "M",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-11-04",
        "last_updated": "2021-09-21",
        "certification_date": "2021-09-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0106X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Pathology",
            "state": "KY",
            "license": "8960",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "KY",
            "license": "8960",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS TN",
            "identifier": "3146210",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRICARE",
            "identifier": "132568",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CARITEN COMMERICAL INSURA",
            "identifier": "702005606",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Bridget Clark, MS,CCC-SLP
• Brittney Lin Clark, APRN
• Donald Dale Clark, R.PH.
• Erin Michelle Clark, LPCC
• Gina K Clark, ARNP
• Jenna Clark
• Kaelin Clark, RBT
• Kayla Clark, LPCA
• Sara Clark
• Steven H Clark

• Oral and Maxillofacial Surgery (Dentist) in Bowling Green, KY
• Providers in Bowling Green, KY by specialty
• Oral and Maxillofacial Surgery (Dentist) in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2021; 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.