Provider Demographics
NPI:1902999873
Name:LACY, DIANA (DDS)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:LACY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7470
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-367-3050
Mailing Address - Fax:847-367-3053
Practice Address - Street 1:747 N MILWAUKEE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-367-3050
Practice Address - Fax:847-367-3053
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist