Provider Demographics
NPI:1679293617
Name:CLARK, STEPHEN PHILLIP (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PHILLIP
Last Name:CLARK
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 1:707 EDGEWATER DR APT 104
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-3619
Mailing Address - Country:US
Mailing Address - Phone:781-927-9597
Mailing Address - Fax:
Practice Address - Street 1:11349 SAMUEL BOWEN BLVD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-2212
Practice Address - Country:US
Practice Address - Phone:866-273-8204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
126800000X
MD177601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No126800000XDental ProvidersDental Assistant