Provider Demographics
NPI:1831297605
Name:LACEY, FREDERICK J (DMD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:LACEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-724-7166
Mailing Address - Fax:607-772-1415
Practice Address - Street 1:116 MURRAY ST
Practice Address - Street 2:
Practice Address - City:BINGHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:13905
Practice Address - Country:US
Practice Address - Phone:607-724-7166
Practice Address - Fax:607-772-1415
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35546122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00647094Medicaid