Provider Demographics
NPI:1508136748
Name:CLARK DENTAL A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:CLARK DENTAL A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:CLARK DENTAL GENERAL AND COSMETIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-251-6810
Mailing Address - Street 1:4420 TOWN CENTER BLVD
Mailing Address - Street 2:280
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7134
Mailing Address - Country:US
Mailing Address - Phone:916-251-6810
Mailing Address - Fax:
Practice Address - Street 1:4420 TOWN CENTER BLVD
Practice Address - Street 2:280
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-7134
Practice Address - Country:US
Practice Address - Phone:916-251-6810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty