=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073939617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD E. CLARKE, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2014
-----------------------------------------------------
Last Update Date | 03/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7616 PACIFIC AVE
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95207-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-952-1641
-----------------------------------------------------
Fax | 209-952-2856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7616 PACIFIC AVE
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95207-1952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-952-1641
-----------------------------------------------------
Fax | 209-952-2856
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, DONALD E. CLARKE, D.D.S.
-----------------------------------------------------
Name | DR. DONALD CLARKE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 916-487-0117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 33738
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------