Provider Demographics
NPI:1033578653
Name:CLARK, MATTHEW MITCHELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MITCHELL
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:MITCHELL
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:101 ZACHARY PL
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-1909
Mailing Address - Country:US
Mailing Address - Phone:865-266-3026
Mailing Address - Fax:
Practice Address - Street 1:716 DENBIGH BLVD STE C1
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4414
Practice Address - Country:US
Practice Address - Phone:757-874-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN109451223S0112X
VA04014174511223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery