Provider Demographics
NPI:1912137282
Name:CLARK, CAMERON (DMD)
Entity Type:Individual
Prefix:
First Name:CAMERON
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 1:3002 SUNROSE CT
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9427
Mailing Address - Country:US
Mailing Address - Phone:503-502-5752
Mailing Address - Fax:541-757-8628
Practice Address - Street 1:869 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4307
Practice Address - Country:US
Practice Address - Phone:541-757-1829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist