Provider Demographics
NPI:1316026669
Name:CLARK, PHILIP K (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:K
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 ISLAND LN STE 12
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4408
Mailing Address - Country:US
Mailing Address - Phone:904-278-7422
Mailing Address - Fax:904-215-1522
Practice Address - Street 1:1590 ISLAND LN STE 12
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4408
Practice Address - Country:US
Practice Address - Phone:904-278-7422
Practice Address - Fax:904-215-1522
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice