Provider Demographics
NPI:1699864520
Name:CLARK, JOHN SAUNDERS (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SAUNDERS
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 1:411 SECURITY SQ
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1922
Mailing Address - Country:US
Mailing Address - Phone:228-896-8355
Mailing Address - Fax:
Practice Address - Street 1:411 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1922
Practice Address - Country:US
Practice Address - Phone:228-896-8355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOR-050-821223X0400X
MS1750-77122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist