Provider Demographics
NPI:1386865137
Name:CLARK, MAXINE VILLIERS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAXINE
Middle Name:VILLIERS
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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
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
Practice Address - Country:US
Practice Address - Phone:410-992-7911
Practice Address - Fax:410-992-0250
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD83001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics