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General NPI Number Information
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NPI Number | 1114064797
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Entity Type | Individual
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Provider Name | GREGORY DALE CLARK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4212 MCEVER RD
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City | OAKWOOD
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State | GA
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Zip | 30566-2237
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Country | US
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Telephone | 770-534-1816
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Fax | 770-534-3059
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Provider Business Mailing Address
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Address Line | 4212 MCEVER ROAD
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City | OAKWOOD
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State | GA
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Zip | 30566
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Country | US
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Telephone | 770-534-4663
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Fax | 770-534-3059
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 8846
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License Number State | GA
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