Healthcare Provider Details

I. General information

NPI: 1033411335
Provider Name (Legal Business Name): MARY JOANN PANEM LECLAIRE R.D.H., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13065 E 17TH AVE MAIL STOP F834
AURORA CO
80045-2532
US

IV. Provider business mailing address

13065 E 17TH AVE MAIL STOP F834
AURORA CO
80045-2532
US

V. Phone/Fax

Practice location:
  • Phone: 303-724-7037
  • Fax: 303-724-7066
Mailing address:
  • Phone: 303-724-7037
  • Fax: 303-724-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2475
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: