Provider Demographics
NPI:1558408930
Name:CLARK, CHARLES LAWRENCE (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LAWRENCE
Last Name:CLARK
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2054
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-8054
Mailing Address - Country:US
Mailing Address - Phone:507-421-0610
Mailing Address - Fax:
Practice Address - Street 1:444 CEDAR ST STE 208
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2186
Practice Address - Country:US
Practice Address - Phone:651-222-1201
Practice Address - Fax:651-760-8633
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001509-151223G0001X
MND81601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice