Provider Demographics
NPI:1760794309
Name:CLARK, JESSICA MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:MICHLLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1300 KEMPSVILLE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6199
Mailing Address - Country:US
Mailing Address - Phone:757-467-7797
Mailing Address - Fax:
Practice Address - Street 1:1300 KEMPSVILLE RD STE 5
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6199
Practice Address - Country:US
Practice Address - Phone:757-467-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry