Healthcare Provider Details

I. General information

NPI: 1003753609
Provider Name (Legal Business Name): LEAH L LACKEY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E LAS VEGAS ST
COLORADO SPRINGS CO
80903-4215
US

IV. Provider business mailing address

3025 N ACADEMY BLVD SUITE 130
COLORADO SPRINGS CO
80917
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax:
Mailing address:
  • Phone: 719-632-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.002023640
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: