Provider Demographics
NPI:1104907617
Name:CLARK, DORRANCE D (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:DORRANCE
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 HOGANS VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513
Mailing Address - Country:US
Mailing Address - Phone:919-244-5178
Mailing Address - Fax:
Practice Address - Street 1:31 OLEANDER DRIVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27527
Practice Address - Country:US
Practice Address - Phone:919-550-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94751223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC736499Medicaid
AZAZ0479180OtherBLUECROSS BLUESHIELD #
AZ736499Medicaid