Provider Demographics
NPI:1760785422
Name:ADAM T CLARK DDS DENTAL CORPORATION
Entity Type:Organization
Organization Name:ADAM T CLARK DDS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-202-4420
Mailing Address - Street 1:26671 ALISO CREEK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4809
Mailing Address - Country:US
Mailing Address - Phone:949-202-4420
Mailing Address - Fax:949-743-0676
Practice Address - Street 1:26671 ALISO CREEK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4809
Practice Address - Country:US
Practice Address - Phone:949-202-4480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA552571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty