Provider Demographics
NPI:1164440491
Name:LACY, ROSA LINDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSA
Middle Name:LINDA
Last Name:LACY
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 1:13 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3601
Mailing Address - Country:US
Mailing Address - Phone:719-384-9442
Mailing Address - Fax:719-384-8880
Practice Address - Street 1:13 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3601
Practice Address - Country:US
Practice Address - Phone:719-384-9442
Practice Address - Fax:719-384-8880
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO61621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02061620Medicaid