Provider Demographics
NPI:1033411335
Name:LECLAIRE, MARY JOANN PANEM (RDH, MS)
Entity Type:Individual
Prefix:PROF
First Name:MARY JOANN
Middle Name:PANEM
Last Name:LECLAIRE
Suffix:
Gender:F
Credentials:RDH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13065 E 17TH AVE
Mailing Address - Street 2:MAIL STOP F834
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2532
Mailing Address - Country:US
Mailing Address - Phone:303-724-7037
Mailing Address - Fax:303-724-7066
Practice Address - Street 1:13065 E 17TH AVE
Practice Address - Street 2:MAIL STOP F834
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2532
Practice Address - Country:US
Practice Address - Phone:303-724-7037
Practice Address - Fax:303-724-7066
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2475124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist