Provider Demographics
NPI:1083758460
Name:MAXINE V. CLARK, D.D.S., P.A.
Entity Type:Organization
Organization Name:MAXINE V. CLARK, D.D.S., P.A.
Other - Org Name:MARYLAND ORTHODONTIC SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:VILLIERS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-992-7911
Mailing Address - Street 1:5094 DORSEY HALL DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7820
Mailing Address - Country:US
Mailing Address - Phone:410-992-7911
Mailing Address - Fax:410-992-0250
Practice Address - Street 1:5094 DORSEY HALL DR
Practice Address - Street 2:SUITE 204
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7820
Practice Address - Country:US
Practice Address - Phone:410-992-7911
Practice Address - Fax:410-992-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8300261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental