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1810 S Crismon Rd Ste 189 Mesa AZ 85209-3717 | |
| (480) 503-3764 | |
| (480) 380-0336 |
| Full Name | |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 1810 S Crismon Rd, Mesa, Arizona |
| Authorized Official Name and Position | Joel R Clark (DDS) |
| Authorized Official Contact | 4805033764 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1810 S Crismon Rd Ste 189 Mesa AZ 85209-3717 Ph: (480) 503-3764 | 1810 S Crismon Rd Ste 189 Mesa AZ 85209-3717 Ph: (480) 503-3764 |
| NPI Number | 1730498320 |
|---|---|
| Provider Enumeration Date | 09/29/2010 |
| Last Update Date | 01/16/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730498320 | NPI | - | NPPES |
| 408928 | Medicaid | AZ | |
| 558133 | Medicaid | AZ | |
| 713546 | Medicaid | AZ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0221X | Dentist - Pediatric Dentistry | 5179 (Arizona) | Primary |
| 1223P0221X | Dentist - Pediatric Dentistry | 7725 (Arizona) | Secondary |
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