Individual
DR. BRADLEY J CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
310 S 9TH AVE, BROKEN BOW, NE 68822-2014
(308) 872-2575
Mailing address
PO BOX 117, 310 SOUTH 9TH AVE., BROKEN BOW, NE 68822-0117
(308) 872-2575
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
6126
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5251
BLUE CROSS BLUE SHIELD #
NE
Enumeration date
02/22/2007
Last updated
07/08/2007
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