Provider Demographics
NPI:1790191393
Name:MARTOGLIO, LACI D (DDS)
Entity Type:Individual
Prefix:DR
First Name:LACI
Middle Name:D
Last Name:MARTOGLIO
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 1:2910 BIG HORN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9365
Mailing Address - Country:US
Mailing Address - Phone:307-587-5588
Mailing Address - Fax:307-587-7123
Practice Address - Street 1:2910 BIG HORN AVE STE A
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9365
Practice Address - Country:US
Practice Address - Phone:307-587-5588
Practice Address - Fax:307-587-7123
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1629483813Medicaid
WY1790191393Medicaid