Provider Demographics
NPI:1619498268
Name:C.J. CLARK AND ASSOCIATES, PC
Entity Type:Organization
Organization Name:C.J. CLARK AND ASSOCIATES, PC
Other - Org Name:SMILES ON NEW BERN AVENUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-991-6843
Mailing Address - Street 1:3301 NASH ST NW STE E
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1642
Mailing Address - Country:US
Mailing Address - Phone:252-991-6843
Mailing Address - Fax:252-991-6854
Practice Address - Street 1:3110 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1200
Practice Address - Country:US
Practice Address - Phone:252-991-6843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093880643Medicaid