Provider Demographics
NPI:1528211786
Name:CLARK, DOUGLAS CRAIG (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CRAIG
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 1:118 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-1481
Mailing Address - Country:US
Mailing Address - Phone:859-630-3281
Mailing Address - Fax:
Practice Address - Street 1:118 W 5TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1481
Practice Address - Country:US
Practice Address - Phone:859-630-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY69621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice