Provider Demographics
NPI:1568817955
Name:SUNDANCE OPTICAL
Entity Type:Organization
Organization Name:SUNDANCE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:602-277-5007
Mailing Address - Street 1:4201 N 16TH ST STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5348
Mailing Address - Country:US
Mailing Address - Phone:602-277-5007
Mailing Address - Fax:602-279-0557
Practice Address - Street 1:4201 N 16TH ST
Practice Address - Street 2:STE 160
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5347
Practice Address - Country:US
Practice Address - Phone:602-277-5007
Practice Address - Fax:602-279-0557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ417332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier