Provider Demographics
NPI:1144668856
Name:ANDREOTTA, LACEY ADDISON (DDS)
Entity type:Individual
Prefix:DR
First Name:LACEY
Middle Name:ADDISON
Last Name:ANDREOTTA
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 1:35330 BOND DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-6136
Mailing Address - Country:US
Mailing Address - Phone:985-707-9122
Mailing Address - Fax:
Practice Address - Street 1:7301 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-2448
Practice Address - Country:US
Practice Address - Phone:504-347-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA63501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1863505Medicaid