Healthcare Provider Details

I. General information

NPI: 1881664696
Provider Name (Legal Business Name): VICTOR M. MOK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 264, MP 388
POLACCA AZ
86042
US

IV. Provider business mailing address

P.O. BOX 4000
POLACCA AZ
86042
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6000
  • Fax: 505-722-1565
Mailing address:
  • Phone: 928-737-6085
  • Fax: 505-722-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS036637
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: