Basic Information
| Provider Information | |||||||||
| NPI: | 1104907617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DORRANCE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 115 | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852470115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281340 | ||||||||
| FaxNumber: | 6025281296 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 W. SEED FARM RD. | ||||||||
| Address2: | |||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025281340 | ||||||||
| FaxNumber: | 6025281296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D6364 | AZ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | AZ0479180 | 01 | AZ | BLUECROSS BLUESHIELD # | OTHER | 736499 | 05 | AZ | MEDICAID |