Provider Demographics
NPI:1619203551
Name:CLARK, JERRY R (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 W FRIENDLY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1844
Mailing Address - Country:US
Mailing Address - Phone:336-273-2528
Mailing Address - Fax:336-273-8038
Practice Address - Street 1:1115 W FRIENDLY AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1844
Practice Address - Country:US
Practice Address - Phone:336-273-2528
Practice Address - Fax:336-273-8038
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA33381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics