Provider Demographics
NPI:1194749978
Name:CLARK, KATHERINE ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BEN CASEY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6567
Mailing Address - Country:US
Mailing Address - Phone:803-547-8200
Mailing Address - Fax:
Practice Address - Street 1:130 BEN CASEY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6567
Practice Address - Country:US
Practice Address - Phone:803-547-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4123122300000X, 1223P0221X
NC90121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry