Provider Demographics
NPI:1982620779
Name:CLARK, GERALD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:A
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1218 VIRGINIA ST E
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-342-4986
Mailing Address - Fax:304-345-4499
Practice Address - Street 1:1218 VIRGINIA ST E
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2951
Practice Address - Country:US
Practice Address - Phone:304-342-4986
Practice Address - Fax:304-345-4499
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4001052-000Medicaid
WV550782922-001OtherBLUE CROSS BLUE SHIELD #
WV979099OtherUNITED CONCORDIA NUMBER