Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 10417 | KY |
Y | 1223P0106X | Oral and Maxillofacial Pathology | 10417 | KY |
NPI | 1215225305 |
---|---|
Provider Name | Ashley Nicole Clark |
First Address | Lexington, KY 40536-0001 |
Second Address | Lexington, KY 40536 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2011 |
Last Update Date | 20/04/2020 |