Provider Demographics
NPI:1356567010
Name:CLARKE, JERRY CARL (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:CARL
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-3834
Mailing Address - Country:US
Mailing Address - Phone:757-428-3477
Mailing Address - Fax:757-428-3477
Practice Address - Street 1:2490 PRUDEN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4206
Practice Address - Country:US
Practice Address - Phone:757-539-9398
Practice Address - Fax:757-539-9492
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA38231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics