Healthcare Provider Details

I. General information

NPI: 1790152403
Provider Name (Legal Business Name): CLARK CHEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 E STILL CIR
MESA AZ
85206-3631
US

IV. Provider business mailing address

5855 E STILL CIR
MESA AZ
85206-3631
US

V. Phone/Fax

Practice location:
  • Phone: 480-219-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number61870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: