Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | D4206 | AZ |
NPI | 1003998683 |
---|---|
Provider Name | Dr. Clarence Chester Schmidt JR. |
First Address | Phoenix, AZ 85009-2102 |
Second Address | Phoenix, AZ 85009-2102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
451914 | AHCCCS ID # (01) | AZ |