Provider Demographics
NPI:1609243955
Name:TUCSON DENTAL IMPLANTS AND PERIODONTICS PLLC
Entity Type:Organization
Organization Name:TUCSON DENTAL IMPLANTS AND PERIODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKELPRANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:310-666-6438
Mailing Address - Street 1:4381 N SUNSET CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6934
Mailing Address - Country:US
Mailing Address - Phone:310-666-6438
Mailing Address - Fax:
Practice Address - Street 1:2330 N ROSEMONT BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2163
Practice Address - Country:US
Practice Address - Phone:310-666-6438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009229261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental