Healthcare Provider Details

I. General information

NPI: 1326278797
Provider Name (Legal Business Name): CALLEE COSBY CLARK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CALLEE ELIZABETH COSBY DDS

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 N 8TH ST SUITE 106
GRAND JUNCTION CO
81501-8857
US

IV. Provider business mailing address

2530 N 8TH ST SUITE 106
GRAND JUNCTION CO
81501-8857
US

V. Phone/Fax

Practice location:
  • Phone: 970-243-7392
  • Fax: 970-243-8086
Mailing address:
  • Phone: 970-243-7392
  • Fax: 970-243-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3621-11
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDEN.00202198
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: