Healthcare Provider Details

I. General information

NPI: 1316301500
Provider Name (Legal Business Name): STEPHEN W. CLARK, DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5963 E SPRING ST
LONG BEACH CA
90808-3752
US

IV. Provider business mailing address

5963 E SPRING ST
LONG BEACH CA
90808-3752
US

V. Phone/Fax

Practice location:
  • Phone: 562-421-8401
  • Fax: 562-421-0523
Mailing address:
  • Phone: 562-421-8401
  • Fax: 562-421-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. STEPHEN W CLARK
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 562-421-8401