Provider Demographics
NPI:1578624359
Name:CLARKE, LANA JOHNSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:JOHNSON
Last Name:CLARKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6142 US HWY 98
Mailing Address - Street 2:STE 10
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8530
Mailing Address - Country:US
Mailing Address - Phone:601-450-1123
Mailing Address - Fax:601-450-1127
Practice Address - Street 1:6142 US HWY 98
Practice Address - Street 2:STE 10
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8530
Practice Address - Country:US
Practice Address - Phone:601-450-1123
Practice Address - Fax:601-450-1127
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3130001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice