Provider Demographics
NPI:1912088410
Name:R. BROOKS LEGG JR.
Entity Type:Organization
Organization Name:R. BROOKS LEGG JR.
Other - Org Name:CLAY DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:LEGG
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-587-4232
Mailing Address - Street 1:63 CARR ST
Mailing Address - Street 2:P.O BOX 568
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-9402
Mailing Address - Country:US
Mailing Address - Phone:304-587-4232
Mailing Address - Fax:304-587-2092
Practice Address - Street 1:63 CARR ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-0000
Practice Address - Country:US
Practice Address - Phone:304-587-4232
Practice Address - Fax:304-587-2092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV21231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005754Medicaid