Active NPI
Edford Leon Clark Jr., DMD
- Dentist
- Prestonsburg, KY
National Provider Identifier
1710927785
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 5490
- Practice address
- 415 North Lake Drive
Ste 201
Prestonsburg, KY 41653 - Phone
- (606) 886-4260
- Fax
- (606) 886-0886
- NPI assigned
- Jun 7, 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 5490 | KY | Primary |
| General Practice Dentistry | 1223G0001X | 5490 | KY |
Addresses
Primary practice location
415 North Lake Drive
Ste 201
Prestonsburg, KY 41653
Mailing address
415 North Lake Drive
Ste 201
Prestonsburg, KY 41653
Phone (606) 886-4260
Other identifiers 7
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 66083861 | Other | BCBS OF AL | |
| 322610 | Other | TIEGEN BCBS | |
| 3147483 | Other | BCBS OF TN | |
| 401559 | Other | UNITED CONCORDIA | |
| 6005L905 | Medicaid | KY | |
| 143184 | Other | VA | BCBS OF VA |
| E914 | Other | FEDERAL BCBS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Previously, effective Aug 25, 2016 through Aug 25, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5490 | KY | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1149638400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1355097600000",
"number": "1710927785",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "415 NORTH LAKE DRIVE",
"address_2": "STE 201",
"city": "PRESTONSBURG",
"state": "KY",
"postal_code": "41653",
"telephone_number": "606-886-4260",
"fax_number": "606-886-0886"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "415 NORTH LAKE DRIVE",
"address_2": "STE 201",
"city": "PRESTONSBURG",
"state": "KY",
"postal_code": "41653",
"telephone_number": "606-886-4260",
"fax_number": "606-886-0886"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "EDFORD",
"middle_name": "LEON",
"name_prefix": "Dr.",
"name_suffix": "Jr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-06-07",
"last_updated": "2012-12-10",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "KY",
"license": "5490",
"primary": true
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "KY",
"license": "5490",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS OF AL",
"identifier": "66083861",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TIEGEN BCBS",
"identifier": "322610",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS OF TN",
"identifier": "3147483",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED CONCORDIA",
"identifier": "401559",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "6005L905",
"state": "KY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS OF VA",
"identifier": "143184",
"state": "VA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FEDERAL BCBS",
"identifier": "E914",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Prestonsburg, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 2012; 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; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.