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General NPI Number Information
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NPI Number | 1366698490
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Entity Type | Individual
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Provider Name | ADAM TANNER CLARK DDS
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Gender | Male
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Dates
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Enumeration Date | 08/08/2008
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Last Update Date | 06/04/2010
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Provider Practice Location Address
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Address Line | 706 E BELL RD SUITE 106
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City | PHOENIX
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State | AZ
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Zip | 85022-6640
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Country | US
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Telephone | 602-996-2600
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Fax | 602-314-6497
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Provider Business Mailing Address
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Address Line | 3131 PAMELA ST
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City | PRESCOTT
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State | AZ
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Zip | 86305-7153
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Country | US
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Telephone | 909-522-6392
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 7396
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 55257
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License Number State | CA
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