Provider Demographics
NPI:1558439174
Name:CHRISTOFFERSEN, CLARK DALE (DDS)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:DALE
Last Name:CHRISTOFFERSEN
Suffix:
Gender:M
Credentials:DDS
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 307
Mailing Address - Street 2:118 E CRAWFORD
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006
Mailing Address - Country:US
Mailing Address - Phone:509-276-2421
Mailing Address - Fax:
Practice Address - Street 1:118 E CRAWFORD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-276-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000050571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE00005057OtherDENTAL