Provider Demographics
NPI:1063418044
Name:CLARK, JEFFREY DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8765 E BELL RD
Mailing Address - Street 2:STE 210
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1321
Mailing Address - Country:US
Mailing Address - Phone:480-585-1853
Mailing Address - Fax:480-585-7695
Practice Address - Street 1:8765 E BELL RD
Practice Address - Street 2:STE 210
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1321
Practice Address - Country:US
Practice Address - Phone:480-585-1853
Practice Address - Fax:480-585-7695
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist