Provider Demographics
NPI:1972610046
Name:DONALD E. CLARKE, D.D.S., INC.
Entity Type:Organization
Organization Name:DONALD E. CLARKE, D.D.S., INC.
Other - Org Name:DENTAL SOURCE OF CALIFORNIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPOATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-487-0117
Mailing Address - Street 1:2200 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7763
Mailing Address - Country:US
Mailing Address - Phone:916-786-6157
Mailing Address - Fax:916-786-0783
Practice Address - Street 1:2200 PROFESSIONAL DR
Practice Address - Street 2:SUITE 210
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7763
Practice Address - Country:US
Practice Address - Phone:916-786-6157
Practice Address - Fax:916-786-0783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33738261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental