Provider Demographics
NPI:1114022720
Name:CLARK, CLEOPHUS BENSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLEOPHUS
Middle Name:BENSON
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 1:5695 KING CENTRE DR
Mailing Address - Street 2:SUITE B100
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5744
Mailing Address - Country:US
Mailing Address - Phone:703-719-9824
Mailing Address - Fax:703-719-6206
Practice Address - Street 1:5695 KING CENTRE DR
Practice Address - Street 2:SUITE B100
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5744
Practice Address - Country:US
Practice Address - Phone:703-719-9824
Practice Address - Fax:703-719-6206
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA38221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice