1255520235 NPI number — COLE AND CLARK DENTAL CORPORATION

Table of content: (NPI 1255520235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255520235 NPI number — COLE AND CLARK DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLE AND CLARK DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255520235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 SOLAR DR
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
OXNARD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93030-8234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-983-3131
Provider Business Mailing Address Fax Number:
805-983-3000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 SOLAR DR
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93030-8234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-983-3131
Provider Business Practice Location Address Fax Number:
805-983-3000
Provider Enumeration Date:
10/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
805-983-3131

Provider Taxonomy Codes

  • Taxonomy code: 1223P0106X , with the licence number:  39247 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 39247 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0008X , with the licence number: 39247 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: B29573-01 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W14838 . This is a "MEDICARE GP #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".