Healthcare Provider Details

I. General information

NPI: 1063496388
Provider Name (Legal Business Name): EDWARD RANDALL MCLEARY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18310 SR 410 E
BONNEY LAKE WA
98391-8532
US

IV. Provider business mailing address

18310 SR 410 E
BONNEY LAKE WA
98391-8532
US

V. Phone/Fax

Practice location:
  • Phone: 253-863-5188
  • Fax: 253-863-4751
Mailing address:
  • Phone: 253-863-5188
  • Fax: 253-863-4751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5019
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: