Provider Demographics
NPI:1285936005
Name:CLARK, JOSEPH R (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-2320
Mailing Address - Country:US
Mailing Address - Phone:706-335-4699
Mailing Address - Fax:
Practice Address - Street 1:42 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-2320
Practice Address - Country:US
Practice Address - Phone:706-335-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN009715122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist