Provider Demographics
NPI:1619382082
Name:CLARK, LAURIE KATHLEEN (RDH)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:KATHLEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14000 N 94TH ST UNIT 2176
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-7792
Mailing Address - Country:US
Mailing Address - Phone:602-909-0587
Mailing Address - Fax:
Practice Address - Street 1:777 E GALVESTON ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-8273
Practice Address - Country:US
Practice Address - Phone:480-812-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH01509124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist