MEDICARE: DR. MCCLARY & ASSOC. WENDOVER, P.A.

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
2	122300000X	Dentist	6541	NC
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
4	122300000X	Dentist
5	1223P0700X	Prosthodontics
6	1223E0200X	Endodontics
7	1223P0300X	Periodontics
8	1223P0221X	Pediatric Dentistry
9	1223G0001X	General Practice Dentistry	8135	NC

General Provider Information

NPI Number	:	1821313446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. MCCLARY & ASSOC. WENDOVER, P.A.

Provider Business Mailing Address
First Line	:	P.O. BOX 860036
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55486
Country	:	US
Telephone Number	:	336-294-5020
Fax Number	:	216-584-1122

Provider Business Practice Location Address
First Line	:	4215 W WENDOVER AVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-1921
Country	:	US
Telephone Number	:	336-294-5020
Fax Number	:	216-584-1122

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. RANDALL LEE MCCLARY
Credential	:	D.D.S.
Telephone Number	:	336-294-5020

Provider Enumeration Date	:	04/07/2010
Last Update Date	:	07/01/2014

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