Provider Demographics
NPI:1659540037
Name:DR. CHRISTOPHER J CLARK DDS AND ASSOCIATES
Entity Type:Organization
Organization Name:DR. CHRISTOPHER J CLARK DDS AND ASSOCIATES
Other - Org Name:DENTAL CENTER AT WATERFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-383-0100
Mailing Address - Street 1:509 OLDE WATERFORD WAY
Mailing Address - Street 2:300
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4125
Mailing Address - Country:US
Mailing Address - Phone:910-383-0100
Mailing Address - Fax:910-383-0121
Practice Address - Street 1:509 OLDE WATERFORD WAY
Practice Address - Street 2:300
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4125
Practice Address - Country:US
Practice Address - Phone:910-383-0100
Practice Address - Fax:910-383-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906097Medicaid