Provider Demographics
NPI:1083840342
Name:CLARK, JACK R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4114
Mailing Address - Country:US
Mailing Address - Phone:205-871-2591
Mailing Address - Fax:205-879-1900
Practice Address - Street 1:1856 LANCASTER RD
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-4114
Practice Address - Country:US
Practice Address - Phone:205-871-2591
Practice Address - Fax:205-879-1900
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL42901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice