MEDICARE: CR CLARK DENTAL, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1831916154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CR CLARK DENTAL, INC.

Provider Business Mailing Address
First Line	:	17909 SOLEDAD CANYON RD STE 160
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91387-3210
Country	:	US
Telephone Number	:	661-250-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	17909 SOLEDAD CANYON RD STE 160
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91387-3210
Country	:	US
Telephone Number	:	661-250-3600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLAYTON R CLARK
Credential	:	DDS
Telephone Number	:	661-250-3600

Provider Enumeration Date	:	09/26/2024
Last Update Date	:	11/14/2024

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