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General NPI Number Information
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NPI Number | 1306014816
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Entity Type | Organization
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Legal Business Name | ANN ARBOR DENTAL SPECIALISTS
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Dates
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Enumeration Date | 02/19/2008
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Last Update Date | 02/19/2008
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Provider Practice Location Address
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Address Line | 3100 E EISENHOWER PKWY SUITE 200
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City | ANN ARBOR
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State | MI
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Zip | 48108-5205
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Country | US
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Telephone | 734-971-3368
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Fax | 734-971-3979
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Provider Business Mailing Address
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Address Line | 3100 E EISENHOWER PKWY SUITE 200
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City | ANN ARBOR
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State | MI
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Zip | 48108-5205
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Country | US
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Telephone | 734-971-3368
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Fax | 734-971-3979
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JAMES W CLARK
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Credential | D.D.S., M.S.
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Telephone | 734-971-3368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 2901018096
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901010113
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License Number State | MI
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