Provider Demographics
NPI:1356434682
Name:MCLELLAN, BARBARA AGNES (DDS)
Entity type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:AGNES
Last Name:MCLELLAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S PONCE DE LEON BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6013
Mailing Address - Country:US
Mailing Address - Phone:904-829-6321
Mailing Address - Fax:904-829-2338
Practice Address - Street 1:1100 S PONCE DE LEON BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6013
Practice Address - Country:US
Practice Address - Phone:904-829-6321
Practice Address - Fax:904-829-2338
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 136721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice