Provider Demographics
NPI:1134492119
Name:CLARK, JAMES D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:D
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 1:32920 BROOKSEED DR
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-4319
Mailing Address - Country:US
Mailing Address - Phone:949-858-8225
Mailing Address - Fax:
Practice Address - Street 1:25733 BARTON RD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3812
Practice Address - Country:US
Practice Address - Phone:909-798-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics