MEDICARE: JACQUELINE CLARY D.M.D, M.S.D.

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	1223P0700X	Prosthodontics	30763	TX

General Provider Information

NPI Number	:	1497130512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE CLARY D.M.D, M.S.D.

Provider Business Mailing Address
First Line	:	1885 EL PASEO ST APT 32307
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-3051
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 BROADWAY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77017-2320
Country	:	US
Telephone Number	:	713-643-2500
Fax Number	:

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

Provider Enumeration Date	:	07/30/2015
Last Update Date	:	04/01/2021

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