Healthcare Provider Details

I. General information

NPI: 1083053029
Provider Name (Legal Business Name): CLARK LOGAN MORRIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 07/31/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 WAKEFIELD PINES DRIVE SUITE 110
RALEIGH NC
27614
US

IV. Provider business mailing address

2800 WAKEFIELD PINES DRIVE SUITE 110
RALEIGH NC
27614
US

V. Phone/Fax

Practice location:
  • Phone: 919-570-0180
  • Fax: 919-570-0280
Mailing address:
  • Phone: 919-570-0180
  • Fax: 919-570-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0442000185
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9927
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: