Provider Demographics
NPI:1346381886
Name:CLARK, CHARLES MILTON (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MILTON
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29709
Mailing Address - Country:US
Mailing Address - Phone:843-623-2053
Mailing Address - Fax:
Practice Address - Street 1:918 HOLLY ST
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709
Practice Address - Country:US
Practice Address - Phone:843-623-2053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ19212Medicaid