Provider Demographics
NPI:1790795086
Name:MCCLURE, MICHAEL THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 KINGSLEY AVE
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4537
Mailing Address - Country:US
Mailing Address - Phone:904-269-1419
Mailing Address - Fax:904-269-1307
Practice Address - Street 1:1409 KINGSLEY AVE
Practice Address - Street 2:SUITE 7A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4537
Practice Address - Country:US
Practice Address - Phone:904-269-1419
Practice Address - Fax:904-269-1307
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 15444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist