Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | DE015629 | MO |
NPI | 1134290323 |
---|---|
Provider Name | Dr. Charles William Clarke |
First Address | Saint Louis, MO 63129-1070 |
Second Address | Saint Louis, MO 63129-1070 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2006 |
Last Update Date | 08/07/2007 |