Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | DT1439 | HI |
NPI | 1316908296 |
---|---|
Provider Name | Dr. Michael Ellsworth Clarke |
First Address | Wailuku, HI 96795 |
Second Address | Wailuku, HI 96795 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1439 | HDS (01) | HI |
52622001 | (05) | HI |
B059978 | HMSA (01) | |
T95540 | (02) |