Provider Demographics
NPI:1184829053
Name:JEFFREY D CLARK D D S P C
Entity Type:Organization
Organization Name:JEFFREY D CLARK D D S P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-585-1853
Mailing Address - Street 1:8765 E BELL RD
Mailing Address - Street 2:STE 201
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1319
Mailing Address - Country:US
Mailing Address - Phone:480-585-1853
Mailing Address - Fax:480-585-7695
Practice Address - Street 1:8765 E BELL RD
Practice Address - Street 2:STE 201
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1319
Practice Address - Country:US
Practice Address - Phone:480-585-1853
Practice Address - Fax:480-585-7695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ149930308122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty