MEDICARE: DR. STACIE LECLAIR DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN15300	FL

General Provider Information

NPI Number	:	1659576601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACIE LECLAIR DMD

Provider Business Mailing Address
First Line	:	2701 PARK DR
Second Line	:	SUITE 6
City	:	CLEARWATER
State	:	FL
Zip	:	33763-1021
Country	:	US
Telephone Number	:	727-474-3700
Fax Number	:	727-474-3702

Provider Business Practice Location Address
First Line	:	2701 PARK DR
Second Line	:	SUITE 6
City	:	CLEARWATER
State	:	FL
Zip	:	33763-1021
Country	:	US
Telephone Number	:	727-474-3700
Fax Number	:	727-474-3702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2007
Last Update Date	:	01/06/2009

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