Healthcare Provider Details

I. General information

NPI: 1255520235
Provider Name (Legal Business Name): COLE AND CLARK DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SOLAR DR #100
OXNARD CA
93030-8234
US

IV. Provider business mailing address

1801 SOLAR DR #100
OXNARD CA
93030-8234
US

V. Phone/Fax

Practice location:
  • Phone: 805-983-3131
  • Fax: 805-983-3000
Mailing address:
  • Phone: 805-983-3131
  • Fax: 805-983-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number39247
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number39247
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number39247
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM JAMES CLARK
Title or Position: OWNER
Credential: DDS, MD
Phone: 805-983-3131