Provider Demographics
NPI:1710384938
Name:CLARK & OTERO DDS PLLC
Entity Type:Organization
Organization Name:CLARK & OTERO DDS PLLC
Other - Org Name:OAK GROVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEBE
Authorized Official - Middle Name:GUNTER
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-863-2377
Mailing Address - Street 1:103 GANYARD FARM WAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703
Mailing Address - Country:US
Mailing Address - Phone:919-597-2444
Mailing Address - Fax:888-505-9592
Practice Address - Street 1:103 GANYARD FARM WAY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-6230
Practice Address - Country:US
Practice Address - Phone:919-957-2444
Practice Address - Fax:888-505-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122300000X, 1223G0001X
NC93871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty