Provider Demographics
NPI:1962574327
Name:DR. CHESTER V. CLARK, JR. D.D.S., M.P.H., P.C.
Entity type:Organization
Organization Name:DR. CHESTER V. CLARK, JR. D.D.S., M.P.H., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:V
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:870-342-5265
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:AMITY
Mailing Address - State:AR
Mailing Address - Zip Code:71921-0154
Mailing Address - Country:US
Mailing Address - Phone:870-342-5265
Mailing Address - Fax:870-342-6292
Practice Address - Street 1:439 E THOMPSON ST
Practice Address - Street 2:
Practice Address - City:AMITY
Practice Address - State:AR
Practice Address - Zip Code:71921-8602
Practice Address - Country:US
Practice Address - Phone:870-342-5265
Practice Address - Fax:870-342-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58932OtherARKANSAS BCBS PROVIDER ID
AR101460608Medicaid
AR809875OtherUNITED CONCORDIA PROVIDER