Provider Demographics
NPI:1134240286
Name:LECLERES, LUIS A (DMD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:LECLERES
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 1:130 CEDAR LN
Mailing Address - Street 2:APT 5N
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4424
Mailing Address - Country:US
Mailing Address - Phone:917-533-3417
Mailing Address - Fax:
Practice Address - Street 1:130 CEDAR LN
Practice Address - Street 2:APT 5N
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4424
Practice Address - Country:US
Practice Address - Phone:917-533-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05003311223G0001X
NY0500331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00050033Medicaid