Provider Demographics
NPI:1043760622
Name:CLAY DENTAL
Entity Type:Organization
Organization Name:CLAY DENTAL
Other - Org Name:GULF COAST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-943-5632
Mailing Address - Street 1:7801 HIGHWAY 59
Mailing Address - Street 2:SUITE F
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535
Mailing Address - Country:US
Mailing Address - Phone:251-943-5632
Mailing Address - Fax:
Practice Address - Street 1:7801 HIGHWAY 59
Practice Address - Street 2:SUITE F
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535
Practice Address - Country:US
Practice Address - Phone:251-943-5632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6083C122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty