Healthcare Provider Details

I. General information

NPI: 1124240023
Provider Name (Legal Business Name): JAMES D. CLARK, DDS, APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26302 LA PAZ RD 202
MISSION VIEJO CA
92691-5313
US

IV. Provider business mailing address

26302 LA PAZ RD SUITE 202
MISSION VIEJO CA
92691-5313
US

V. Phone/Fax

Practice location:
  • Phone: 949-830-4101
  • Fax:
Mailing address:
  • Phone: 949-830-4101
  • Fax: 949-830-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number26364
License Number StateCA

VIII. Authorized Official

Name: DR. JAMES D. CLARK
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 949-830-4101