1679898241 NPI number — CHRISTOPHER J CLARK, DDS, PA

Table of content: (NPI 1679898241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679898241 NPI number — CHRISTOPHER J CLARK, DDS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTOPHER J CLARK, DDS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL CENTER AT BRIER CREEK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679898241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLADENBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28320-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-863-2377
Provider Business Mailing Address Fax Number:
910-863-2555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7841 ALEXANDER PROMENADE PL
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27617-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-863-2377
Provider Business Practice Location Address Fax Number:
910-863-2555
Provider Enumeration Date:
04/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
910-863-2377

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  7917 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5901223 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 749621 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".




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