Individual
DR. GERALD A CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1218 VIRGINIA ST E, SUITE B, CHARLESTON, WV 25301-2951
(304) 342-4986
(304) 345-4499
Mailing address
1218 VIRGINIA ST E, SUITE B, CHARLESTON, WV 25301
(304) 342-4986
(304) 345-4499
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
3372
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4001052-000
—
WV
01
—
550782922-001
BLUE CROSS BLUE SHIELD #
WV
01
—
979099
UNITED CONCORDIA NUMBER
WV
Enumeration date
07/14/2006
Last updated
07/09/2007
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