Healthcare Provider Details

I. General information

NPI: 1780830489
Provider Name (Legal Business Name): DR. MCCLARY & ASSOC. WAKE FOREST, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11480 CAPITAL BLVD. SUITE 115 CAVENESS FARMS
WAKE FOREST NC
27587-4554
US

IV. Provider business mailing address

P.O. BOX 860036
MINNEAPOLIS MN
55486
US

V. Phone/Fax

Practice location:
  • Phone: 919-570-9898
  • Fax: 216-584-1120
Mailing address:
  • Phone: 919-570-9898
  • Fax: 216-584-1120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL MCCLARY
Title or Position: DENTIST/OWNER
Credential: D.D.S.
Phone: 800-487-4867