Healthcare Provider Details

I. General information

NPI: 1710944772
Provider Name (Legal Business Name): BRETT GUY CLERC DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 S OCOTILLO
BENSON AZ
85602-2046
US

IV. Provider business mailing address

PO BOX 2046
BENSON AZ
85602-2046
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-7056
  • Fax: 520-586-0770
Mailing address:
  • Phone: 520-586-7056
  • Fax: 520-586-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4014
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: