Healthcare Provider Details

I. General information

NPI: 1134809205
Provider Name (Legal Business Name): COSBY ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 N 8TH ST STE 104
GRAND JUNCTION CO
81501-8856
US

IV. Provider business mailing address

2530 N 8TH ST STE 104
GRAND JUNCTION CO
81501-8856
US

V. Phone/Fax

Practice location:
  • Phone: 970-243-7392
  • Fax:
Mailing address:
  • Phone: 970-243-7392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. CALLEE CLARK
Title or Position: ENDODONTIST
Credential: DDS
Phone: 901-679-7697