Healthcare Provider Details

I. General information

NPI: 1134194582
Provider Name (Legal Business Name): VIVIAN L CLARK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BDC NORTH ISLAND BOX 357037
SAN DIEGO CA
92135-7037
US

IV. Provider business mailing address

795 RIVER ROCK RD
CHULA VISTA CA
91914-2431
US

V. Phone/Fax

Practice location:
  • Phone: 619-545-6398
  • Fax:
Mailing address:
  • Phone: 619-397-5705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number9175
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: