=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972610046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONALD E. CLARKE, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 01/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 PROFESSIONAL DR SUITE 210
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-7763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-786-6157
-----------------------------------------------------
Fax | 916-786-0783
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 PROFESSIONAL DR SUITE 210
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-7763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-786-6157
-----------------------------------------------------
Fax | 916-786-0783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPOATION PRESIDENT
-----------------------------------------------------
Name | DR. DONALD CLARKE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 916-487-0117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 33738
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------