Provider Demographics
NPI:1154814838
Name:CLARK, HOLLIS ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOLLIS
Middle Name:ANNE
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 1:743 WORDSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1986
Mailing Address - Country:US
Mailing Address - Phone:225-368-6479
Mailing Address - Fax:
Practice Address - Street 1:15420 S HARRELLS FERRY RD STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2933
Practice Address - Country:US
Practice Address - Phone:225-753-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA68461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice