Provider Demographics
NPI:1316908296
Name:CLARKE, MICHAEL ELLSWORTH (DDS MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ELLSWORTH
Last Name:CLARKE
Suffix:
Gender:M
Credentials:DDS MS
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Mailing Address - Street 1:24 N CHURCH ST
Mailing Address - Street 2:#206
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96795
Mailing Address - Country:US
Mailing Address - Phone:808-242-0077
Mailing Address - Fax:808-243-8007
Practice Address - Street 1:24 N CHURCH ST
Practice Address - Street 2:#206
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96795
Practice Address - Country:US
Practice Address - Phone:808-242-0077
Practice Address - Fax:808-243-8007
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
HIDT1439204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1439OtherHDS
HI52622001Medicaid
B059978OtherHMSA
T95540Medicare UPIN