Provider Demographics
NPI:1629082516
Name:LACO, EDWARD PETER JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PETER
Last Name:LACO
Suffix:JR
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 1:309 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4520
Mailing Address - Country:US
Mailing Address - Phone:815-633-1815
Mailing Address - Fax:815-633-1627
Practice Address - Street 1:309 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4520
Practice Address - Country:US
Practice Address - Phone:815-633-1815
Practice Address - Fax:815-633-1627
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-025905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist