Provider Demographics
NPI:1952415903
Name:MCCLENAHAN, DAVID CARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CARY
Last Name:MCCLENAHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 SOUTH MILWAUKEE AVENUE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3267
Mailing Address - Country:US
Mailing Address - Phone:847-362-6650
Mailing Address - Fax:847-362-7902
Practice Address - Street 1:755 SOUTH MILWAUKEE AVENUE
Practice Address - Street 2:SUITE 120
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3267
Practice Address - Country:US
Practice Address - Phone:847-362-6650
Practice Address - Fax:847-362-7902
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19018102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
36240Medicare UPIN
IL990250Medicare ID - Type UnspecifiedPROVIDER NUMBER