Provider Demographics
NPI:1639322233
Name:CLARK, JANICE D (DDS)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:D
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 1:2211 EXECUTIVE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3661
Mailing Address - Country:US
Mailing Address - Phone:704-395-6000
Mailing Address - Fax:704-398-7373
Practice Address - Street 1:2041 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5147
Practice Address - Country:US
Practice Address - Phone:336-777-1272
Practice Address - Fax:336-777-1196
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice