Provider Demographics
NPI:1073644068
Name:MICHAEL E CLARKE DDSMS INC
Entity Type:Organization
Organization Name:MICHAEL E CLARKE DDSMS INC
Other - Org Name:MICHAEL E. CLARKE DDSMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ELLSWORTH
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,M S
Authorized Official - Phone:808-242-0077
Mailing Address - Street 1:24 N CHURCH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1680
Mailing Address - Country:US
Mailing Address - Phone:808-242-0077
Mailing Address - Fax:808-243-8007
Practice Address - Street 1:24 N CHURCH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1680
Practice Address - Country:US
Practice Address - Phone:808-242-0077
Practice Address - Fax:808-243-8007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI526220-01Medicaid
HI00C0059976OtherHAWAII MEDICAL SERVICE AS
HI1439OtherHAWAII DENTAL SERVICE
HI00C0059976OtherHAWAII MEDICAL SERVICE AS