Provider Demographics
NPI:1396874863
Name:LECLAIR, JOHN WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:LECLAIR
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 1:1315 WEST COLLEGE AVE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801
Mailing Address - Country:US
Mailing Address - Phone:814-954-7620
Mailing Address - Fax:814-237-3062
Practice Address - Street 1:1315 WEST COLLEGE AVE.
Practice Address - Street 2:SUITE 201
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801
Practice Address - Country:US
Practice Address - Phone:814-954-7620
Practice Address - Fax:814-308-9985
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017092L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010324310001Medicaid