Provider Demographics
NPI:1326278797
Name:CLARK, CALLEE COSBY (DDS)
Entity Type:Individual
Prefix:
First Name:CALLEE
Middle Name:COSBY
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CALLEE
Other - Middle Name:ELIZABETH
Other - Last Name:COSBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2530 N 8TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8857
Mailing Address - Country:US
Mailing Address - Phone:970-243-7392
Mailing Address - Fax:970-243-8086
Practice Address - Street 1:2530 N 8TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8857
Practice Address - Country:US
Practice Address - Phone:970-243-7392
Practice Address - Fax:970-243-8086
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3621-111223E0200X
CODEN.002021981223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics