Provider Demographics
NPI:1457468779
Name:MCCLELLAN, GERALD W (DDS)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:W
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 W BAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92661-1015
Mailing Address - Country:US
Mailing Address - Phone:949-675-2415
Mailing Address - Fax:
Practice Address - Street 1:1801 NEWPORT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2701
Practice Address - Country:US
Practice Address - Phone:949-645-6631
Practice Address - Fax:949-645-2051
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice