Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 7725537-9921 | UT |
Y | 1223E0200X | Endodontist | 7725537-9921 | UT |
NPI | 1033425863 |
---|---|
Provider Name | Dr. Collin R Clatanoff |
First Address | Phoenix, AZ 85018-9181 |
Second Address | Phoenix, AZ 85018 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2010 |
Last Update Date | 12/06/2018 |