Provider Demographics
NPI:1548265192
Name:LACY,JR., EDWARD JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:LACY,JR.
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 ABARR DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3156
Mailing Address - Country:US
Mailing Address - Phone:970-667-2372
Mailing Address - Fax:970-635-9737
Practice Address - Street 1:2550 ABARR DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3156
Practice Address - Country:US
Practice Address - Phone:970-667-2372
Practice Address - Fax:970-635-9737
Is Sole Proprietor?:No
Enumeration Date:2005-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO58991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02589901Medicaid