Healthcare Provider Details

I. General information

NPI: 1255506861
Provider Name (Legal Business Name): CHRISTOPHER CLARK DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 FOURTH ST
BLADENBORO NC
28320
US

IV. Provider business mailing address

104 FOURTH ST
BLADENBORO NC
28320
US

V. Phone/Fax

Practice location:
  • Phone: 910-863-2377
  • Fax: 910-863-2555
Mailing address:
  • Phone: 910-863-2377
  • Fax: 910-863-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7917
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8366
License Number StateNC

VIII. Authorized Official

Name: CHRISTOPHER J CLARK
Title or Position: OWNER
Credential: DDS
Phone: 910-863-2377