MEDICARE: DR. RICHARD MCCLAVE DMD

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	1223G0001X	General Practice Dentistry	13508	MD
2	1223G0001X	General Practice Dentistry	DD3063	NM

General Provider Information

NPI Number	:	1780612820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD MCCLAVE DMD

Provider Business Mailing Address
First Line	:	2917 CUTLER AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-1714
Country	:	US
Telephone Number	:	443-694-2185
Fax Number	:

Provider Business Practice Location Address
First Line	:	1231 CANDELARIA RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-2767
Country	:	US
Telephone Number	:	505-345-8309
Fax Number	:

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	02/19/2009

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