Provider Demographics
NPI:1639246887
Name:LACY, GREGORY ALAN (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:LACY
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 CHESTNUT RIDGE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2822
Mailing Address - Country:US
Mailing Address - Phone:304-598-2500
Mailing Address - Fax:304-598-2517
Practice Address - Street 1:918 CHESTNUT RIDGE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2822
Practice Address - Country:US
Practice Address - Phone:304-598-2500
Practice Address - Fax:304-598-2517
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135456000Medicaid