Provider Demographics
NPI:1346546314
Name:CHRISTOPHER CLARK, DDS & ASSOCIATES, PA
Entity Type:Organization
Organization Name:CHRISTOPHER CLARK, DDS & ASSOCIATES, PA
Other - Org Name:MINI CITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-863-2377
Mailing Address - Street 1:4558 CAPITAL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-4538
Mailing Address - Country:US
Mailing Address - Phone:910-863-2377
Mailing Address - Fax:910-863-2555
Practice Address - Street 1:4558 CAPITAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-4538
Practice Address - Country:US
Practice Address - Phone:910-863-2377
Practice Address - Fax:910-863-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty