Active NPI
Rebecca Leann Clark
- Dentist
- Elizaetthtown, KY
National Provider Identifier
1801528336
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 10811
- Practice address
- 2030 N Dixie Hwy
Elizaetthtown, KY 42701 - Phone
- (270) 763-0200
- NPI assigned
- Jun 24, 2022
- Sex
- Female
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Dentist | 122300000X | 10811 | KY | Primary |
Addresses
Primary practice location
2030 N Dixie Hwy
Elizaetthtown, KY 42701
Mailing address
7865B Estrada Ave
Fort Knox, KY 40121-2321
Phone (972) 765-5186
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 |
|---|---|---|---|
| 10811 | KY | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1656028800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1656028800000",
"number": "1801528336",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7865B ESTRADA AVE",
"city": "FORT KNOX",
"state": "KY",
"postal_code": "401212321",
"telephone_number": "972-765-5186"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2030 N DIXIE HWY",
"city": "ELIZAETTHTOWN",
"state": "KY",
"postal_code": "42701",
"telephone_number": "270-763-0200"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "REBECCA",
"middle_name": "LEANN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2022-06-24",
"last_updated": "2022-06-24",
"certification_date": "2022-06-17",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "KY",
"license": "10811",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.