Provider Demographics
NPI:1477173367
Name:LECLAIR, SUSAN B (RDH, BS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:LECLAIR
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6824 BRIGHTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1100
Mailing Address - Country:US
Mailing Address - Phone:248-860-1119
Mailing Address - Fax:
Practice Address - Street 1:6824 BRIGHTWOOD CT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1100
Practice Address - Country:US
Practice Address - Phone:248-860-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902006713124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2902006713OtherMDHHS