Provider Demographics
NPI:1588183404
Name:MCCLARIE, ELESE (DMD)
Entity Type:Individual
Prefix:
First Name:ELESE
Middle Name:
Last Name:MCCLARIE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 ROSEHILL RD APT 24
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-2475
Mailing Address - Country:US
Mailing Address - Phone:303-994-1456
Mailing Address - Fax:
Practice Address - Street 1:2040 CENTRAL CT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6276
Practice Address - Country:US
Practice Address - Phone:920-468-0504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002250-151223G0001X
IL019.0313941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice