Provider Demographics
NPI:1942747183
Name:JOHN W. LECLAIR DMD
Entity Type:Organization
Organization Name:JOHN W. LECLAIR DMD
Other - Org Name:DENTAL HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LECLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-441-4432
Mailing Address - Street 1:1315 W COLLEGE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-2776
Mailing Address - Country:US
Mailing Address - Phone:814-954-7620
Mailing Address - Fax:814-308-9985
Practice Address - Street 1:1315 W COLLEGE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2776
Practice Address - Country:US
Practice Address - Phone:814-954-7620
Practice Address - Fax:814-308-9985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017092L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010324310005Medicaid