Provider Demographics
NPI:1811381916
Name:WILLMAN, LACEY (DDS)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:WILLMAN
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 1:10850 N 90TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6737
Mailing Address - Country:US
Mailing Address - Phone:480-657-6357
Mailing Address - Fax:
Practice Address - Street 1:10850 N 90TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-657-6357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
AZ9490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program