=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023239449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S. CHRIS CLARK, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7200 S PENNSYLVANIA AVE STE B
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-3336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-681-6668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 S PENNSYLVANIA AVE STE B
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-3336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-681-6668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN OF THE BOARD
-----------------------------------------------------
Name | DR. STEPHEN CHRIS CLARK
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 405-681-6668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | OK4100
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------