Provider Demographics
NPI:1801969282
Name:MCCLARAN, JERRY TODD (DMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:TODD
Last Name:MCCLARAN
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 1:2688 SUNSET LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909
Mailing Address - Country:US
Mailing Address - Phone:954-401-3362
Mailing Address - Fax:
Practice Address - Street 1:2688 SUNSET LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909
Practice Address - Country:US
Practice Address - Phone:954-401-3362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL181521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice