Provider Demographics
NPI:1679923080
Name:VANDERWALL-LACEY, CHARITY JE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARITY
Middle Name:JE
Last Name:VANDERWALL-LACEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:
Other - Last Name:VANDER WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:123 COBIA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6862
Mailing Address - Country:US
Mailing Address - Phone:910-347-1211
Mailing Address - Fax:
Practice Address - Street 1:123 COBIA CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6862
Practice Address - Country:US
Practice Address - Phone:910-347-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1001627122300000X
NC10800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist