Provider Demographics
NPI:1063019404
Name:BLACKWELL, LACEY TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:TODD
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6206 DUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2510
Mailing Address - Country:US
Mailing Address - Phone:540-793-5965
Mailing Address - Fax:
Practice Address - Street 1:5954 HARBOUR PARK DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2163
Practice Address - Country:US
Practice Address - Phone:804-739-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401417212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist