Provider Demographics
NPI:1235486507
Name:MACKELPRANG, CLARK (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:
Last Name:MACKELPRANG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 N ROSEMONT BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2159
Mailing Address - Country:US
Mailing Address - Phone:520-327-0263
Mailing Address - Fax:520-327-0965
Practice Address - Street 1:2330 N ROSEMONT BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2159
Practice Address - Country:US
Practice Address - Phone:520-327-0263
Practice Address - Fax:520-327-0965
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0092291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics