Provider Demographics
NPI:1205255460
Name:CLAYCOMO DENTAL GROUP LLC
Entity type:Organization
Organization Name:CLAYCOMO DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEWANICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-454-1313
Mailing Address - Street 1:244 E US HIGHWAY 69
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-3184
Mailing Address - Country:US
Mailing Address - Phone:816-454-1313
Mailing Address - Fax:816-454-5377
Practice Address - Street 1:244 E US HIGHWAY 69
Practice Address - Street 2:SUITE 101
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-3184
Practice Address - Country:US
Practice Address - Phone:816-454-1313
Practice Address - Fax:816-454-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009016386261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental