Provider Demographics
NPI:1578867354
Name:CLARK, RUPERT BANCROFT JR (DDS)
Entity type:Individual
Prefix:DR
First Name:RUPERT
Middle Name:BANCROFT
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 G ST SW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20024-2723
Mailing Address - Country:US
Mailing Address - Phone:202-554-5500
Mailing Address - Fax:202-554-4550
Practice Address - Street 1:509 G ST SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-2723
Practice Address - Country:US
Practice Address - Phone:202-554-5500
Practice Address - Fax:202-554-4550
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN22301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice