Provider Demographics
NPI:1619193216
Name:GOOD HOPE DENTAL CENTER PC
Entity Type:Organization
Organization Name:GOOD HOPE DENTAL CENTER PC
Other - Org Name:CLARK FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:MALCOLM
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:256-350-8182
Mailing Address - Street 1:203 COMMERCE CIR SW STE B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6840
Mailing Address - Country:US
Mailing Address - Phone:256-350-8182
Mailing Address - Fax:256-350-3232
Practice Address - Street 1:203 COMMERCE CIR SW STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-6840
Practice Address - Country:US
Practice Address - Phone:256-350-8182
Practice Address - Fax:256-350-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty