Provider Demographics
NPI:1275737405
Name:CLARK DENTISTRY, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CLARK DENTISTRY, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-494-1445
Mailing Address - Street 1:330 PARK AVE
Mailing Address - Street 2:#10
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2352
Mailing Address - Country:US
Mailing Address - Phone:949-494-1445
Mailing Address - Fax:949-494-1215
Practice Address - Street 1:330 PARK AVE
Practice Address - Street 2:#10
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2352
Practice Address - Country:US
Practice Address - Phone:949-494-1445
Practice Address - Fax:949-494-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194863555Medicare UPIN