Healthcare Provider Details

I. General information

NPI: 1710137559
Provider Name (Legal Business Name): SCOTT R MCCLURE DDS MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 LAKE BOONE TRL SUITE 1A
RALEIGH NC
27607-7503
US

IV. Provider business mailing address

4601 LAKE BOONE TRL SUITE 1A
RALEIGH NC
27607-7503
US

V. Phone/Fax

Practice location:
  • Phone: 919-786-4470
  • Fax: 919-786-4471
Mailing address:
  • Phone: 919-786-4470
  • Fax: 919-786-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8662
License Number StateNC

VIII. Authorized Official

Name: DR. SCOTT RYAN MCCLURE
Title or Position: PRESIDENT
Credential: D.D.S., M.S.
Phone: 919-786-4470