Christopher J Clark, DDS
Individual provider
Active NPI
Dentist · Zebulon, NC
NPI 1093880643 · NPPES record last updated Dec 8, 2008
Key facts
- NPI
- 1093880643
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 7917 (NC)
- Practice address
- 877 E Gannon Ave
Zebulon, NC 27597-9314
- Phone
- (919) 269-0103
- Fax
- (910) 863-2555
- NPI assigned
- Nov 21, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NC
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|
| I20160603000864 |
NC |
Order and Referring Only - Dentist
Practitioner - Dentist |
1052601069 |
|
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|
| 7917 | NC | MD | Orthopedic Physical Therapist |
Practice roles
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|
| Dentist |
122300000X |
7917 |
NC |
Yes |
Addresses
Primary practice location
877 E Gannon Ave
Zebulon, NC 27597-9314
Mailing address
877 E Gannon Ave
Zebulon, NC 27597-9314
Phone (919) 269-0103
Other identifiers
| Identifier | Type | State | Issuer |
|---|
| 5901223 | Medicaid | NC | |