Provider Demographics
NPI:1366698490
Name:CLARK, ADAM TANNER (DDS)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:TANNER
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3131 PAMELA ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7153
Mailing Address - Country:US
Mailing Address - Phone:909-522-6392
Mailing Address - Fax:
Practice Address - Street 1:706 E BELL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-6640
Practice Address - Country:US
Practice Address - Phone:602-996-2600
Practice Address - Fax:602-314-6497
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ73961223S0112X
CA552571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7396OtherDENTAL LICENSE
CA55257OtherSTATE LICENSE