Provider Demographics
NPI:1649355850
Name:CLARKE, J. HENRY (DMD)
Entity type:Individual
Prefix:
First Name:J.
Middle Name:HENRY
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 NE 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4965
Mailing Address - Country:US
Mailing Address - Phone:503-288-1618
Mailing Address - Fax:
Practice Address - Street 1:611 SW CAMPUS DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3001
Practice Address - Country:US
Practice Address - Phone:503-494-4316
Practice Address - Fax:503-494-8384
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD3630122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist