Provider Demographics
NPI:1619280807
Name:GREENWALD, LACEY NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:NICOLE
Last Name:GREENWALD
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 1:307 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3419
Mailing Address - Country:US
Mailing Address - Phone:319-524-2728
Mailing Address - Fax:
Practice Address - Street 1:307 N 17TH ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3419
Practice Address - Country:US
Practice Address - Phone:319-524-2728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice