Provider Demographics
NPI:1669595880
Name:CARROLL, CLARK M (DMD,PC)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DMD,PC
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 4007
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-4007
Mailing Address - Country:US
Mailing Address - Phone:478-374-7184
Mailing Address - Fax:478-374-4238
Practice Address - Street 1:750 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6736
Practice Address - Country:US
Practice Address - Phone:478-374-7184
Practice Address - Fax:478-374-4238
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180290Medicaid
GA00044976AMedicaid
GA100952Medicaid