Provider Demographics
NPI:1093704207
Name:CLARK, CHRISTOPHER BRETT (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:BRETT
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:BRETT
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:190 HEMPSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6248
Mailing Address - Country:US
Mailing Address - Phone:860-447-3216
Mailing Address - Fax:860-701-6019
Practice Address - Street 1:190 HEMPSTEAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6248
Practice Address - Country:US
Practice Address - Phone:860-447-3216
Practice Address - Fax:860-701-6019
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry