Provider Demographics
NPI:1689937526
Name:SPARKMAN, CLARISSA MARY (DMD)
Entity Type:Individual
Prefix:MRS
First Name:CLARISSA
Middle Name:MARY
Last Name:SPARKMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:CLARISSA
Other - Middle Name:MARY
Other - Last Name:SLIWOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:802 W 42ND ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3222
Mailing Address - Country:US
Mailing Address - Phone:218-263-8381
Mailing Address - Fax:218-263-8383
Practice Address - Street 1:802 W 42ND ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3222
Practice Address - Country:US
Practice Address - Phone:218-263-8381
Practice Address - Fax:218-263-8383
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1518086750Medicaid
ND40058Medicaid