Healthcare Provider Details

I. General information

NPI: 1811381916
Provider Name (Legal Business Name): LACEY WILLMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 N 90TH ST
SCOTTSDALE AZ
85260
US

IV. Provider business mailing address

10850 N 90TH ST
SCOTTSDALE AZ
85260-6737
US

V. Phone/Fax

Practice location:
  • Phone: 480-657-6357
  • Fax:
Mailing address:
  • Phone: 480-657-6357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9490
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: