Provider Demographics
NPI:1558825208
Name:ROCKY RIVER FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ROCKY RIVER FAMILY DENTISTRY
Other - Org Name:PAUL S CLARKE IV DMD PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:807-777-8088
Mailing Address - Street 1:7239 BAYBROOKE LN
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-8381
Mailing Address - Country:US
Mailing Address - Phone:704-282-3356
Mailing Address - Fax:
Practice Address - Street 1:3475 US HIGHWAY 601 S
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0490
Practice Address - Country:US
Practice Address - Phone:704-282-3356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental