Provider Demographics
NPI:1205494127
Name:CLARK, CHRISTOPHER (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
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 257
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MS
Mailing Address - Zip Code:38917-0257
Mailing Address - Country:US
Mailing Address - Phone:901-484-9001
Mailing Address - Fax:
Practice Address - Street 1:60 MARKET CENTER DR
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-7077
Practice Address - Country:US
Practice Address - Phone:901-850-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4050-191223G0001X
TN110671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice