MEDICARE: JAQUERIA BRIANNA LACY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center		NC

General Provider Information

NPI Number	:	1841093788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAQUERIA BRIANNA LACY DMD

Provider Business Mailing Address
First Line	:	99 KNEELAND ST APT 603
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02111-2436
Country	:	US
Telephone Number	:	863-279-2887
Fax Number	:

Provider Business Practice Location Address
First Line	:	2066 NC HIGHWAY 125 # 603
Second Line	:
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-9436
Country	:	US
Telephone Number	:	863-279-2887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2025
Last Update Date	:	05/19/2026

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