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General NPI Number Information
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NPI Number | 1558408930
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Entity Type | Individual
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Provider Name | CHARLES LAWRENCE CLARK DDS
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Gender | Male
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 03/02/2025
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Provider Practice Location Address
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Address Line | 444 CEDAR ST STE 208
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City | SAINT PAUL
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State | MN
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Zip | 55101-2186
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Country | US
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Telephone | 651-222-1201
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Fax | 651-760-8633
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Provider Business Mailing Address
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Address Line | PO BOX 2054
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City | INVER GROVE HEIGHTS
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State | MN
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Zip | 55076-8054
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Country | US
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Telephone | 507-421-0610
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Fax |
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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 | 5001509-15
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D8160
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License Number State | MN
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