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General NPI Number Information
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NPI Number | 1356567010
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Entity Type | Individual
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Provider Name | JERRY CARL CLARKE DDS
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Gender | Male
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2490 PRUDEN BLVD
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City | SUFFOLK
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State | VA
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Zip | 23434-4206
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Country | US
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Telephone | 757-539-9398
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Fax | 757-539-9492
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Provider Business Mailing Address
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Address Line | 510 CAVALIER DR
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City | VIRGINIA BEACH
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State | VA
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Zip | 23451-3834
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Country | US
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Telephone | 757-428-3477
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Fax | 757-428-3477
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3823
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License Number State | VA
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