Provider Demographics
NPI:1073939617
Name:DONALD E. CLARKE, D.D.S., INC.
Entity Type:Organization
Organization Name:DONALD E. CLARKE, D.D.S., INC.
Other - Org Name:DENTAL SOURCE OF CALIFORNIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, DONALD E. CLARKE, D.D.S.
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-487-0117
Mailing Address - Street 1:7616 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-1952
Mailing Address - Country:US
Mailing Address - Phone:209-952-1641
Mailing Address - Fax:209-952-2856
Practice Address - Street 1:7616 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-1952
Practice Address - Country:US
Practice Address - Phone:209-952-1641
Practice Address - Fax:209-952-2856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty