Provider Demographics
NPI:1851489447
Name:CLARK, WALEED AJAMU (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALEED
Middle Name:AJAMU
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 1:612 BELLEMEADE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1903
Mailing Address - Country:US
Mailing Address - Phone:202-271-3096
Mailing Address - Fax:
Practice Address - Street 1:1813 EASTCHESTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-1573
Practice Address - Country:US
Practice Address - Phone:336-882-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC80571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2410632Medicare UPIN