Provider Demographics
NPI:1780802983
Name:CLAY, MICHAEL BRADLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRADLEY
Last Name:CLAY
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 1:108 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2008
Mailing Address - Country:US
Mailing Address - Phone:618-684-6461
Mailing Address - Fax:
Practice Address - Street 1:108 N 14TH ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2008
Practice Address - Country:US
Practice Address - Phone:618-684-6461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190267921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice