Provider Demographics
NPI:1669640876
Name:CLARK & GOSSETT IMPLANT AND ORAL SURGERY, PA
Entity Type:Organization
Organization Name:CLARK & GOSSETT IMPLANT AND ORAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GOSSETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:830-625-6914
Mailing Address - Street 1:3013 INDEPENDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132
Mailing Address - Country:US
Mailing Address - Phone:830-625-6914
Mailing Address - Fax:830-629-5530
Practice Address - Street 1:3013 INDEPENDENCE DRIVE
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132
Practice Address - Country:US
Practice Address - Phone:830-625-6914
Practice Address - Fax:830-629-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170231223S0112X
TX188161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty