Active NPI
Jerry R Clark, DDS, MS
- Orthodontics and Dentofacial Orthopedics Dentistry
- Greensboro, NC
National Provider Identifier
1619203551
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry
- License
- 3338
- Practice address
- 1115 W Friendly Ave
Greensboro, NC 27401-1844 - Phone
- (336) 273-2528
- Fax
- (336) 273-8038
- NPI assigned
- Oct 28, 2009
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | 3338 | PA | Primary |
Addresses
Primary practice location
1115 W Friendly Ave
Greensboro, NC 27401-1844
Mailing address
1115 W Friendly Ave
Greensboro, NC 27401-1844
Phone (336) 273-2528
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3338 | PA | MD | Orthodontics and Dentofacial Orthopedic Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1256688000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1256688000000",
"number": "1619203551",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1115 W FRIENDLY AVE",
"city": "GREENSBORO",
"state": "NC",
"postal_code": "274011844",
"telephone_number": "336-273-2528",
"fax_number": "336-273-8038"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1115 W FRIENDLY AVE",
"city": "GREENSBORO",
"state": "NC",
"postal_code": "274011844",
"telephone_number": "336-273-2528",
"fax_number": "336-273-8038"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "JERRY",
"middle_name": "R",
"name_prefix": "Dr.",
"credential": "DDS, MS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2009-10-28",
"last_updated": "2009-10-28",
"status": "A"
},
"taxonomies": [
{
"code": "1223X0400X",
"taxonomy_group": "",
"desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
"state": "PA",
"license": "3338",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Greensboro, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.