Provider Demographics
NPI:1760091409
Name:CLARK, MEREDITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEREDITH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7797 BARRENSDALE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1713
Mailing Address - Country:US
Mailing Address - Phone:248-514-5132
Mailing Address - Fax:
Practice Address - Street 1:8472 SIMMOND ST
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5700
Practice Address - Country:US
Practice Address - Phone:301-677-6983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016004771223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice