Provider Demographics
NPI:1497756985
Name:LACY, RAYMOND A II (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:A
Last Name:LACY
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 BAYSIDE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6723
Mailing Address - Country:US
Mailing Address - Phone:707-822-4826
Mailing Address - Fax:707-822-7467
Practice Address - Street 1:791 BAYSIDE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6723
Practice Address - Country:US
Practice Address - Phone:707-822-4826
Practice Address - Fax:707-822-7467
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2008-01-09
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CA229021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADS0229020Medicare ID - Type Unspecified