MEDICARE: CLIFTON WAITE MCCONNELL DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	015693	MO
2	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1851436414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLIFTON WAITE MCCONNELL DMD

Provider Business Mailing Address
First Line	:	3016 NORTH KENTWOOD
Second Line	:	SPRINGFIELD DENTURE CENTER
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-4414
Country	:	US
Telephone Number	:	417-833-1474
Fax Number	:	417-833-1243

Provider Business Practice Location Address
First Line	:	3016 NORTH KENTWOOD
Second Line	:	SPRINGFIELD DENTURE CENTER
City	:	SPRINGFIELD
State	:	MO
Zip	:	65803-4414
Country	:	US
Telephone Number	:	417-833-1474
Fax Number	:	417-833-1243

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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