Provider Demographics
NPI:1922061936
Name:CLARK, JILL A (RDH)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:A
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:3776 ELM DR
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3912
Mailing Address - Country:US
Mailing Address - Phone:808-744-0007
Mailing Address - Fax:
Practice Address - Street 1:755 SCOTT CIR
Practice Address - Street 2:BLDG 559
Practice Address - City:HICKAM AFB
Practice Address - State:HI
Practice Address - Zip Code:96853-5399
Practice Address - Country:US
Practice Address - Phone:808-448-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402203160124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist