MEDICARE: DR. JOEL R. CLARK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	5179	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790759439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOEL R. CLARK D.D.S.

Provider Business Mailing Address
First Line	:	1925 S SOSSAMAN RD
Second Line	:	211
City	:	MESA
State	:	AZ
Zip	:	85209-4275
Country	:	US
Telephone Number	:	480-503-3764
Fax Number	:	480-380-0336

Provider Business Practice Location Address
First Line	:	1925 S SOSSAMAN RD
Second Line	:	211
City	:	MESA
State	:	AZ
Zip	:	85209-4275
Country	:	US
Telephone Number	:	480-503-3764
Fax Number	:	480-380-0336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	07/08/2007

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