Healthcare Provider Details

I. General information

NPI: 1922061936
Provider Name (Legal Business Name): JILL A CLARK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL A CLARKE RDH

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SCOTT CIR BLDG 559
HICKAM AFB HI
96853-5399
US

IV. Provider business mailing address

3776 ELM DR
PEARL CITY HI
96782-3912
US

V. Phone/Fax

Practice location:
  • Phone: 808-448-6371
  • Fax:
Mailing address:
  • Phone: 808-744-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402203160
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: