=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598879538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A. GAVIN MCCLURE, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 LINCOLN ST
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95060-4333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-426-1343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 LINCOLN ST
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95060-4333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AUSTIN GAVIN MCCLURE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 831-426-1343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 38446
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------