Provider Demographics
NPI:1891879656
Name:CLARKSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30558-0353
Mailing Address - Country:US
Mailing Address - Phone:706-865-0357
Mailing Address - Fax:
Practice Address - Street 1:3431 MURPHY HWY
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512
Practice Address - Country:US
Practice Address - Phone:706-865-0357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice