Provider Demographics
NPI:1114412103
Name:SULLIVAN, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 BROCKS GAP PKWY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4032
Mailing Address - Country:US
Mailing Address - Phone:205-982-0112
Mailing Address - Fax:
Practice Address - Street 1:1015 BROCKS GAP PKWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4032
Practice Address - Country:US
Practice Address - Phone:205-982-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist