MEDICARE: JILL A CLARK RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	0402203160	VA

General Provider Information

NPI Number	:	1922061936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL A CLARK RDH

Provider Business Mailing Address
First Line	:	3776 ELM DR
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-3912
Country	:	US
Telephone Number	:	808-744-0007
Fax Number	:

Provider Business Practice Location Address
First Line	:	755 SCOTT CIR
Second Line	:	BLDG 559
City	:	HICKAM AFB
State	:	HI
Zip	:	96853-5399
Country	:	US
Telephone Number	:	808-448-6371
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	08/06/2012

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