Healthcare Provider Details

I. General information

NPI: 1376270934
Provider Name (Legal Business Name): LACEY CARROLL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 N 3RD ST
GOSHEN IN
46528-7100
US

IV. Provider business mailing address

814 N 3RD ST
GOSHEN IN
46528-7100
US

V. Phone/Fax

Practice location:
  • Phone: 574-500-3737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: