Provider Demographics
NPI:1083777445
Name:CLARK, JOANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOANN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 EXECUTIVE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6606
Mailing Address - Country:US
Mailing Address - Phone:757-838-9486
Mailing Address - Fax:757-838-5542
Practice Address - Street 1:2214 EXECUTIVE DR
Practice Address - Street 2:SUITE A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6606
Practice Address - Country:US
Practice Address - Phone:757-838-9486
Practice Address - Fax:757-838-5542
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010059351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice