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General NPI Number Information
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NPI Number | 1740420629
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Entity Type | Individual
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Provider Name | CRISTON C. CLARK D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/04/2009
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Last Update Date | 03/04/2009
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Provider Practice Location Address
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Address Line | 7102 NASHVILLE ST
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City | RINGGOLD
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State | GA
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Zip | 30736-2446
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Country | US
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Telephone | 706-965-7272
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Fax | 706-965-7279
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Provider Business Mailing Address
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Address Line | PO BOX 934
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City | RINGGOLD
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State | GA
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Zip | 30736-0934
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Country | US
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Telephone | 706-965-7272
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Fax | 706-965-7279
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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 | 011280
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License Number State | GA
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