Organization
BENNIE CLARK JR DMD PA
Active
Other names
Soutel Dental Center II
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LORRAINE POLITE CLARK DMD (VICE PRESIDENT)
(904) 722-2200
Entity
Organization
Contact information
Practice address
5475 SOUTEL DR, JACKSONVILLE, FL 32219-3464
(904) 764-4576
(904) 722-9900
Mailing address
5475 SOUTEL DR, JACKSONVILLE, FL 32219-3464
(904) 764-4576
(904) 722-2200
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
124Q00000X
Dental Hygienist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
071395300
—
FL
Enumeration date
07/19/2011
Last updated
11/01/2019
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