Provider Demographics
NPI:1235642828
Name:JESSICA M. CLARK, DDS
Entity Type:Organization
Organization Name:JESSICA M. CLARK, DDS
Other - Org Name:JESSICA M. CLARK, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-467-7797
Mailing Address - Street 1:1300 KEMPSVILLE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6199
Mailing Address - Country:US
Mailing Address - Phone:757-467-7797
Mailing Address - Fax:
Practice Address - Street 1:1300 KEMPSVILLE RD STE 5
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6199
Practice Address - Country:US
Practice Address - Phone:757-467-7797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTIC DENTAL CARE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA040414143341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty