Provider Demographics
NPI:1801814512
Name:LACAYO, MARLENE A (DDS)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:A
Last Name:LACAYO
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 1:510 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-2633
Mailing Address - Country:US
Mailing Address - Phone:605-224-9771
Mailing Address - Fax:
Practice Address - Street 1:1323 BIA ROUTE 4
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339-0200
Practice Address - Country:US
Practice Address - Phone:605-245-1518
Practice Address - Fax:605-245-2150
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY45-7101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5549010Medicaid
SD5549010Medicaid