Provider Demographics
NPI:1548571078
Name:CLARK FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CLARK FAMILY DENTISTRY
Other - Org Name:KIRKLAND W. CLARK, III, D.M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRKLAND
Authorized Official - Middle Name:WOODRUFF
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-534-5550
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-0517
Mailing Address - Country:US
Mailing Address - Phone:803-534-5550
Mailing Address - Fax:803-534-3963
Practice Address - Street 1:630 LAUREL ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4835
Practice Address - Country:US
Practice Address - Phone:803-534-5550
Practice Address - Fax:803-534-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty