| Organization Name: | MAXINE V. CLARK, D.D.S., P.A. |
| NPI Number: | 1083758460 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MAXINE VILLIERS CLARK (CEO) |
| Mailing Address: | 5094 Dorsey Hall Dr Suite 204 Ellicott City |
| State: | MD US |
| Postal Code: | 210427820 |
| Phone Number: | 4109927911 |
| Fax Number: | 4109920250 |
| NPI Enumeration Date: | 02/17/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 8300 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MD |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |