Provider Demographics
NPI:1629020649
Name:STURDIVANT, H CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:H
Middle Name:CLARK
Last Name:STURDIVANT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 POLK ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6532
Mailing Address - Country:US
Mailing Address - Phone:360-385-0567
Mailing Address - Fax:
Practice Address - Street 1:608 POLK ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6532
Practice Address - Country:US
Practice Address - Phone:360-385-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA79741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice