Provider Demographics
NPI:1780753053
Name:CLARK, JAMES ROBERT
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12413 FREMONT DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-6995
Mailing Address - Country:US
Mailing Address - Phone:804-364-1170
Mailing Address - Fax:
Practice Address - Street 1:12413 FREMONT DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-6995
Practice Address - Country:US
Practice Address - Phone:804-364-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist