Healthcare Provider Details

I. General information

NPI: 1164312757
Provider Name (Legal Business Name): CALEB CLARK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5213 W NAPOLEON AVE
METAIRIE LA
70001-2266
US

IV. Provider business mailing address

1712 RIDGEWOOD PL
VESTAVIA HILLS AL
35216-1630
US

V. Phone/Fax

Practice location:
  • Phone: 504-455-2182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD.007465-C1
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7812
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: