Healthcare Provider Details

I. General information

NPI: 1104156744
Provider Name (Legal Business Name): DONALD E. CLARKE, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 5TH ST
MODESTO CA
95351-2810
US

IV. Provider business mailing address

1015 5TH ST
MODESTO CA
95351-2810
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-4263
  • Fax: 209-577-2056
Mailing address:
  • Phone: 209-577-4263
  • Fax: 209-577-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DONALD CLARKE
Title or Position: CORPORATION PRESIDENT
Credential: D.D.S.
Phone: 916-487-0117