Provider Demographics
NPI:1497116313
Name:W.A. CLARK D.D.S., P.L.L.C.
Entity Type:Organization
Organization Name:W.A. CLARK D.D.S., P.L.L.C.
Other - Org Name:CLARK PEDIATRIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-503-9615
Mailing Address - Street 1:612 BELLEMEADE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1813 EASTCHESTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-1573
Practice Address - Country:US
Practice Address - Phone:405-503-9615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC80571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2410632Medicare UPIN