Provider Demographics
NPI:1699178913
Name:LACLAIR FAMILY DENTAL, PLLC
Entity type:Organization
Organization Name:LACLAIR FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LACLAIR
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-493-1184
Mailing Address - Street 1:111 S MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-1606
Mailing Address - Country:US
Mailing Address - Phone:315-493-1184
Mailing Address - Fax:315-519-1545
Practice Address - Street 1:111 S MECHANIC ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-1606
Practice Address - Country:US
Practice Address - Phone:315-493-1184
Practice Address - Fax:315-519-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0513831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03075647Medicaid