Provider Demographics
NPI:1093880643
Name:CLARK, CHRISTOPHER J (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 E GANNON AVE
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-9314
Mailing Address - Country:US
Mailing Address - Phone:919-269-0103
Mailing Address - Fax:910-863-2555
Practice Address - Street 1:877 E GANNON AVE
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-9314
Practice Address - Country:US
Practice Address - Phone:919-269-0103
Practice Address - Fax:910-863-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901223Medicaid