Healthcare Provider Details

I. General information

NPI: 1841093788
Provider Name (Legal Business Name): JAQUERIA BRIANNA LACY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 NC HIGHWAY 125 # 603
ROANOKE RAPIDS NC
27870-9436
US

IV. Provider business mailing address

PO BOX 640
ROANOKE RAPIDS NC
27870-0640
US

V. Phone/Fax

Practice location:
  • Phone: 863-279-2887
  • Fax:
Mailing address:
  • Phone: 252-536-5844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14889
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: