Provider Demographics
NPI:1457917767
Name:CLARK, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:CLARK
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 1:2110 N FOUNTAIN GREEN RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-1414
Mailing Address - Country:US
Mailing Address - Phone:410-474-3629
Mailing Address - Fax:
Practice Address - Street 1:2110 N FOUNTAIN GREEN RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-1414
Practice Address - Country:US
Practice Address - Phone:410-638-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD177541223G0001X
PADS0420511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice