Provider Demographics
NPI:1871677476
Name:CLARK, PATRICIA LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 SOLANA RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2297
Mailing Address - Country:US
Mailing Address - Phone:904-280-1717
Mailing Address - Fax:904-280-1525
Practice Address - Street 1:751 OAK ST
Practice Address - Street 2:601
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3359
Practice Address - Country:US
Practice Address - Phone:904-354-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN119481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice