Provider Demographics
NPI:1053464560
Name:DR. CLYDE A. MAXWELL JR, PA
Entity Type:Organization
Organization Name:DR. CLYDE A. MAXWELL JR, PA
Other - Org Name:GENTLE TOUCH FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-740-5124
Mailing Address - Street 1:188 FRIES MILL RD
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2015
Mailing Address - Country:US
Mailing Address - Phone:856-740-5124
Mailing Address - Fax:856-740-5127
Practice Address - Street 1:303 E LEA BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-2353
Practice Address - Country:US
Practice Address - Phone:302-765-3373
Practice Address - Fax:302-765-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-0001159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000040828Medicaid