Active NPI
Jefferson Clark, DDS
- Prosthodontics
- Roseville, CA
National Provider Identifier
1609318443
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Prosthodontics
- License
- 63225
- Practice address
- 2350 Professional Dr
Suite 100
Roseville, CA 95661-7747 - Phone
- (916) 783-0122
- NPI assigned
- Nov 10, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Prosthodontics | 1223P0700X | 63225 | CA | Primary |
Addresses
Primary practice location
2350 Professional Dr
Suite 100
Roseville, CA 95661-7747
Mailing address
2350 Professional Dr
Suite 100
Roseville, CA 95661-7747
Phone (916) 783-0122
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 63225 | CA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1478736000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1478736000000",
"number": "1609318443",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2350 PROFESSIONAL DR",
"address_2": "SUITE 100",
"city": "ROSEVILLE",
"state": "CA",
"postal_code": "956617747",
"telephone_number": "916-783-0122"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2350 PROFESSIONAL DR",
"address_2": "SUITE 100",
"city": "ROSEVILLE",
"state": "CA",
"postal_code": "956617747",
"telephone_number": "916-783-0122"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "JEFFERSON",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2016-11-10",
"last_updated": "2016-11-10",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0700X",
"taxonomy_group": "",
"desc": "Dentist, Prosthodontics",
"state": "CA",
"license": "63225",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Roseville, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 10, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.