Provider Demographics
NPI:1073134276
Name:COOPER, LACEY LEE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 WOODBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7146
Mailing Address - Country:US
Mailing Address - Phone:509-301-2081
Mailing Address - Fax:
Practice Address - Street 1:3189 MAPLE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2501
Practice Address - Country:US
Practice Address - Phone:770-998-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist