Provider Demographics
NPI:1932071503
Name:CLARK, DOMINIQUE (DC)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1212
Mailing Address - Country:US
Mailing Address - Phone:201-501-8984
Mailing Address - Fax:
Practice Address - Street 1:17 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1212
Practice Address - Country:US
Practice Address - Phone:201-501-8984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00813900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor