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General NPI Number Information
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NPI Number | 1114022720
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Entity Type | Individual
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Provider Name | CLEOPHUS BENSON CLARK DDS
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Gender | Male
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Dates
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Enumeration Date | 09/14/2006
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 5695 KING CENTRE DR SUITE B100
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City | ALEXANDRIA
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State | VA
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Zip | 22315-5744
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Country | US
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Telephone | 703-719-9824
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Fax | 703-719-6206
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Provider Business Mailing Address
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Address Line | 5695 KING CENTRE DR SUITE B100
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City | ALEXANDRIA
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State | VA
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Zip | 22315-5744
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Country | US
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Telephone | 703-719-9824
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Fax | 703-719-6206
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401003822
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License Number State | VA
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