Provider Demographics
NPI:1285835991
Name:DR. DARRELL ADRIAN CLARK D.D.S.
Entity Type:Organization
Organization Name:DR. DARRELL ADRIAN CLARK D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS PA
Authorized Official - Phone:301-856-1234
Mailing Address - Street 1:3102 DUNKAGLE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1261
Mailing Address - Country:US
Mailing Address - Phone:301-218-1622
Mailing Address - Fax:301-218-1623
Practice Address - Street 1:8839 BRANCH AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2632
Practice Address - Country:US
Practice Address - Phone:301-856-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD83081223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty