Provider Demographics
NPI:1427241058
Name:CLARK, JAY F (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:F
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 1:7455 ERIE RD
Mailing Address - Street 2:P.O. BOX 417
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9305
Mailing Address - Country:US
Mailing Address - Phone:716-947-4308
Mailing Address - Fax:
Practice Address - Street 1:7455 ERIE RD
Practice Address - Street 2:LAKE SHORE PROF BLDG
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9305
Practice Address - Country:US
Practice Address - Phone:716-947-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0358711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice