Provider Demographics
NPI:1619065133
Name:CLARKE, MICHAEL ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 E LANIKAULA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4362
Mailing Address - Country:US
Mailing Address - Phone:808-969-3830
Mailing Address - Fax:808-969-1189
Practice Address - Street 1:31 E LANIKAULA ST
Practice Address - Street 2:SUITE B
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4362
Practice Address - Country:US
Practice Address - Phone:808-969-3830
Practice Address - Fax:808-969-1189
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02278001Medicaid