Provider Demographics
NPI:1043007305
Name:CLEARY, CAILIN
Entity type:Individual
Prefix:
First Name:CAILIN
Middle Name:
Last Name:CLEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2523
Mailing Address - Country:US
Mailing Address - Phone:516-984-4820
Mailing Address - Fax:
Practice Address - Street 1:6900 FOREST AVE STE 110
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1730
Practice Address - Country:US
Practice Address - Phone:804-893-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYNA1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program