Provider Demographics
NPI:1740521509
Name:W.A. CLARK, D.D.S., P.L.L.C.
Entity type:Organization
Organization Name:W.A. CLARK, D.D.S., P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALEED
Authorized Official - Middle Name:AJAMU
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-271-3096
Mailing Address - Street 1:612 BELLEMEADE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1903
Mailing Address - Country:US
Mailing Address - Phone:202-271-3096
Mailing Address - Fax:
Practice Address - Street 1:1040 NE 36TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-5002
Practice Address - Country:US
Practice Address - Phone:405-427-5405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty