Healthcare Provider Details

I. General information

NPI: 1568478477
Provider Name (Legal Business Name): CLYDE A MAXWELL JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E LEA BLVD
WILMINGTON DE
19802-2353
US

IV. Provider business mailing address

303 E LEA BLVD
WILMINGTON DE
19802-2353
US

V. Phone/Fax

Practice location:
  • Phone: 302-765-3373
  • Fax: 302-765-3379
Mailing address:
  • Phone: 302-765-3373
  • Fax: 302-765-3379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberG1-0001159
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: