Provider Demographics
NPI:1992928006
Name:CLARK, DARRELL ADRIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:ADRIAN
Last Name:CLARK
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 1:3102 DUNKAGLE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1261
Mailing Address - Country:US
Mailing Address - Phone:301-218-1622
Mailing Address - Fax:301-218-1623
Practice Address - Street 1:12070 OLD LINE CTR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2513
Practice Address - Country:US
Practice Address - Phone:301-638-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD83081223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics