Provider Demographics
NPI:1083696082
Name:LACEY, DENNIS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MICHAEL
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:D.
Other - Middle Name:MICHAEL
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1100 JOHNSON FERRY RD NE
Mailing Address - Street 2:BLDG 1, SUITE 425
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-252-2666
Mailing Address - Fax:404-252-0890
Practice Address - Street 1:1100 JOHNSON FERRY RD NE
Practice Address - Street 2:BLDG 1, SUITE 425
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-252-2666
Practice Address - Fax:404-252-0890
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029704174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
40381Medicare UPIN
GA40381Medicare UPIN