MEDICARE: CHARLES M CLARK DMD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1921	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457369308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES M CLARK DMD PA

Provider Business Mailing Address
First Line	:	PO BOX 70
Second Line	:
City	:	CHESTERFIELD
State	:	SC
Zip	:	29709
Country	:	US
Telephone Number	:	843-623-2053
Fax Number	:

Provider Business Practice Location Address
First Line	:	918 HOLLY ST
Second Line	:
City	:	CHESTERFIELD
State	:	SC
Zip	:	29709
Country	:	US
Telephone Number	:	843-623-2053
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES MILTON CLARK
Credential	:	DMD
Telephone Number	:	843-623-2053

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	06/16/2008

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