Provider Demographics
NPI:1740543776
Name:CLARK GENERAL DENTISTRY CENTER, P.C.
Entity type:Organization
Organization Name:CLARK GENERAL DENTISTRY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:478-746-0046
Mailing Address - Street 1:1918 FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1144
Mailing Address - Country:US
Mailing Address - Phone:478-746-0046
Mailing Address - Fax:478-746-0970
Practice Address - Street 1:1918 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1144
Practice Address - Country:US
Practice Address - Phone:478-746-0046
Practice Address - Fax:478-746-0970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty