MEDICARE: C JEFF CLAY, D.D.S. INC.

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	2683	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1591884	OTHER	WV	UNITRED CONCORDIA
2	001875982	OTHER	WV	MOUNTAIN STATE BLUE CROSS

General Provider Information

NPI Number	:	1982765517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C JEFF CLAY, D.D.S. INC.

Provider Business Mailing Address
First Line	:	479 FLAT TOP RD
Second Line	:
City	:	SHADY SPRING
State	:	WV
Zip	:	25918-8614
Country	:	US
Telephone Number	:	304-763-4665
Fax Number	:	304-763-5172

Provider Business Practice Location Address
First Line	:	479 FLAT TOP RD
Second Line	:
City	:	SHADY SPRING
State	:	WV
Zip	:	25918
Country	:	US
Telephone Number	:	304-763-4665
Fax Number	:	304-763-5172

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CARL JEFFREY CLAY
Credential	:	D. D.S.
Telephone Number	:	304-763-4665

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	01/26/2009

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