Provider Demographics
NPI:1447311725
Name:CLARK, STEPHEN W (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:W
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5963 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-3752
Mailing Address - Country:US
Mailing Address - Phone:562-421-8401
Mailing Address - Fax:562-421-0523
Practice Address - Street 1:5963 E SPRING ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-3752
Practice Address - Country:US
Practice Address - Phone:562-421-8401
Practice Address - Fax:562-421-0523
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA209951223E0200X, 1223P0300X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223E0200XDental ProvidersDentistEndodontics
No1223P0300XDental ProvidersDentistPeriodontics