Provider Demographics
NPI:1417398553
Name:CLARK, SHAWNA (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAWNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5366 MENDENHALL MALL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-4505
Mailing Address - Country:US
Mailing Address - Phone:901-701-2730
Mailing Address - Fax:901-271-6195
Practice Address - Street 1:5366 MENDENHALL MALL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4505
Practice Address - Country:US
Practice Address - Phone:901-701-2730
Practice Address - Fax:901-271-6195
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN97021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice