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1366698490 NPI number — ADAM TANNER CLARK DDS

NPI Number: 1366698490
Health Care Provider/Practitioner: ADAM TANNER CLARK DDS

Information about “1366698490” NPI (ADAM TANNER CLARK DDS) exists in 1366698490 in HTML format HTML  |  1366698490 in plain Text format TXT  |  1366698490 in PDF (Portable Document Format) PDF  |  1366698490 in an XML format XML  formats.

NPI Number : 1366698490 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1366698490",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CLARK",
    "FirstName": "ADAM",
    "MiddleName": "TANNER",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "DDS",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "3131 PAMELA ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "PRESCOTT",
    "MailingAddressStateName": "AZ",
    "MailingAddressPostalCode": "86305-7153",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "909-522-6392",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "706 E BELL RD",
    "SecondLinePracticeLocationAddress": "SUITE 106",
    "PracticeLocationAddressCityName": "PHOENIX",
    "PracticeLocationAddressStateName": "AZ",
    "PracticeLocationAddressPostalCode": "85022-6640",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "602-996-2600",
    "PracticeLocationAddressFaxNumber": "602-314-6497",
    "EnumerationDate": "08/08/2008",
    "LastUpdateDate": "06/04/2010",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "1223S0112X",
          "TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
          "LicenseNumber": "7396",
          "LicenseNumberStateCode": "AZ",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "1223S0112X",
          "TaxonomyName": "Oral and Maxillofacial Surgery (Dentist)",
          "LicenseNumber": "55257",
          "LicenseNumberStateCode": "CA",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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