Provider Demographics
NPI:1578186060
Name:OVERMAN, LACIE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:LACIE
Middle Name:
Last Name:OVERMAN
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 1:360 PEAK ONE DR # 100
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-5948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DR # 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-5948
Practice Address - Country:US
Practice Address - Phone:970-668-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO124Q00000X
CODH.002025752124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist