Provider Demographics
NPI:1780872119
Name:CLARKE, TANYA JANE (RDH)
Entity type:Individual
Prefix:MR
First Name:TANYA
Middle Name:JANE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:TANYA
Other - Middle Name:JANE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1404 CENTRAL AVE S STE 101
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-7433
Mailing Address - Country:US
Mailing Address - Phone:206-296-4586
Mailing Address - Fax:
Practice Address - Street 1:1404 CENTRAL AVE S STE 101
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7433
Practice Address - Country:US
Practice Address - Phone:206-296-4586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00002710124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist