Provider Demographics
NPI:1710241344
Name:STRANGE, CLARKE STEWART
Entity Type:Individual
Prefix:
First Name:CLARKE
Middle Name:STEWART
Last Name:STRANGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 I 55 N
Mailing Address - Street 2:HIGHLAND VILLAGE SUITE 235
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N
Practice Address - Street 2:HIGHLAND VILLAGE SUITE 235
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5930
Practice Address - Country:US
Practice Address - Phone:601-987-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3660-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice