Provider Demographics
NPI:1134194582
Name:CLARK, VIVIAN L (RDH)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 RIVER ROCK RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-2431
Mailing Address - Country:US
Mailing Address - Phone:619-397-5705
Mailing Address - Fax:
Practice Address - Street 1:BDC NORTH ISLAND
Practice Address - Street 2:BOX 357037
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135-7037
Practice Address - Country:US
Practice Address - Phone:619-545-6398
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9175124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist