Provider Demographics
NPI:1134503444
Name:C BENSON CLARK, DDS, PC
Entity Type:Organization
Organization Name:C BENSON CLARK, DDS, PC
Other - Org Name:KING CENTRE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEOPHUS
Authorized Official - Middle Name:BENSON
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:703-719-9824
Mailing Address - Street 1:5695 KING CENTRE DR
Mailing Address - Street 2:STE. B-100
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:
Practice Address - Street 1:5695 KING CENTRE DR
Practice Address - Street 2:STE. B-100
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010038221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty