Provider Demographics
NPI:1124089545
Name:MCCLAIN, JEFFREY RICHARD (DMD, MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
Last Name:MCCLAIN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8893 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2351
Mailing Address - Country:US
Mailing Address - Phone:330-856-7950
Mailing Address - Fax:
Practice Address - Street 1:8893 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2351
Practice Address - Country:US
Practice Address - Phone:330-856-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH196841223S0112X
OH75926204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2114063Medicaid
OHG93612Medicare UPIN
OH2114063Medicaid