Provider Demographics
NPI:1417103482
Name:CLARK, CHARLIE E (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLIE
Middle Name:E
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 1:15264 W BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-3989
Mailing Address - Country:US
Mailing Address - Phone:623-474-3975
Mailing Address - Fax:623-474-3198
Practice Address - Street 1:15264 W BROOKSIDE LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3989
Practice Address - Country:US
Practice Address - Phone:623-474-3975
Practice Address - Fax:623-474-3198
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7793122300000X
WI6303-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist