Provider Demographics
NPI:1063618916
Name:QUEEN CREEK PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:QUEEN CREEK PEDIATRIC DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-503-3764
Mailing Address - Street 1:7400 S POWER RD
Mailing Address - Street 2:BLDG 6, STE 132
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297
Mailing Address - Country:US
Mailing Address - Phone:480-503-3764
Mailing Address - Fax:480-380-0336
Practice Address - Street 1:7400 S POWER RD
Practice Address - Street 2:BLDG 6, STE 132
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297
Practice Address - Country:US
Practice Address - Phone:480-503-3764
Practice Address - Fax:480-380-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty