Provider Demographics
NPI:1568478477
Name:MAXWELL, CLYDE A JR (DDS)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:A
Last Name:MAXWELL
Suffix:JR
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 1:303 E LEA BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-2353
Mailing Address - Country:US
Mailing Address - Phone:302-765-3373
Mailing Address - Fax:302-765-3379
Practice Address - Street 1:303 E LEA BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-2353
Practice Address - Country:US
Practice Address - Phone:302-765-3373
Practice Address - Fax:302-765-3379
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-0001159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000015890Medicaid