Provider Demographics
NPI:1790759439
Name:CLARK, JOEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:R
Last Name:CLARK
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Gender:M
Credentials:DDS
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Mailing Address - Street 1:1925 S SOSSAMAN RD
Mailing Address - Street 2:211
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4275
Mailing Address - Country:US
Mailing Address - Phone:480-503-3764
Mailing Address - Fax:480-380-0336
Practice Address - Street 1:1925 S SOSSAMAN RD
Practice Address - Street 2:211
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-4275
Practice Address - Country:US
Practice Address - Phone:480-503-3764
Practice Address - Fax:480-380-0336
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
AZ51791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ713546Medicaid