Provider Demographics
NPI:1710060322
Name:CLARK, DAVID MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
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 1:10228 ANTIETAM CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-0802
Mailing Address - Country:US
Mailing Address - Phone:804-313-7190
Mailing Address - Fax:
Practice Address - Street 1:5205 COURTHOUSE RD STE 201
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22551-6326
Practice Address - Country:US
Practice Address - Phone:540-895-7330
Practice Address - Fax:540-895-7328
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice