Provider Demographics
NPI:1255354213
Name:MUTALE, CLARA (DMD)
Entity type:Individual
Prefix:DR
First Name:CLARA
Middle Name:
Last Name:MUTALE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 W WISTERIA PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4027
Mailing Address - Country:US
Mailing Address - Phone:480-250-2419
Mailing Address - Fax:
Practice Address - Street 1:2175 N ALMA SCHOOL RD
Practice Address - Street 2:C-108
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2878
Practice Address - Country:US
Practice Address - Phone:480-782-6200
Practice Address - Fax:480-792-1444
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13405122300000X
AZD71291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02617Medicare UPIN