Provider Demographics
NPI:1205118460
Name:CLARK, CLAYTON ROSELL (DDS)
Entity type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:ROSELL
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 AUTO CENTER DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550
Mailing Address - Country:US
Mailing Address - Phone:661-945-2616
Mailing Address - Fax:
Practice Address - Street 1:2635 GATEWAY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-1753
Practice Address - Country:US
Practice Address - Phone:760-431-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA604321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice