Provider Demographics
NPI:1598724296
Name:DU LAC, KATHLEEN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:DU LAC
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 N PINE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2305
Mailing Address - Country:US
Mailing Address - Phone:407-340-4922
Mailing Address - Fax:
Practice Address - Street 1:2500 W LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-328-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN170881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice