Provider Demographics
NPI:1891845160
Name:CLARK DENTAL CARE INC
Entity Type:Organization
Organization Name:CLARK DENTAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:ABDEL BASIR
Authorized Official - Last Name:ABDEL WAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-342-5370
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078
Mailing Address - Country:US
Mailing Address - Phone:937-342-5370
Mailing Address - Fax:
Practice Address - Street 1:1980 A KINGS GATE RD
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502
Practice Address - Country:US
Practice Address - Phone:937-342-5370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0679565Medicaid