Provider Demographics
NPI:1457424434
Name:CLARK, JAY REGAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:REGAN
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 1:20 S PINES RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5136
Mailing Address - Country:US
Mailing Address - Phone:509-891-5299
Mailing Address - Fax:509-891-6852
Practice Address - Street 1:20 S PINES RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-5136
Practice Address - Country:US
Practice Address - Phone:509-891-5299
Practice Address - Fax:509-891-6852
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA76631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5024112Medicaid
WA262582Medicare UPIN