Provider Demographics
NPI:1346201431
Name:CLARK, JASON DREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DREW
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 1:7810 PROVIDENCE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-2987
Mailing Address - Country:US
Mailing Address - Phone:704-543-3766
Mailing Address - Fax:704-543-3768
Practice Address - Street 1:7810 PROVIDENCE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-2987
Practice Address - Country:US
Practice Address - Phone:704-543-3766
Practice Address - Fax:704-543-3768
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990141Medicaid