Provider Demographics
NPI:1790117448
Name:CHANEY, CLARK CHRISTOPHER (DDS)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:CHRISTOPHER
Last Name:CHANEY
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 1:5247 ROE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2374
Mailing Address - Country:US
Mailing Address - Phone:913-515-1561
Mailing Address - Fax:
Practice Address - Street 1:4121 W 83RD ST STE 206
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-5323
Practice Address - Country:US
Practice Address - Phone:913-381-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist