Provider Demographics
NPI:1891128385
Name:LACEY, CHRISTEN C (RDH, ECP III)
Entity Type:Individual
Prefix:
First Name:CHRISTEN
Middle Name:C
Last Name:LACEY
Suffix:
Gender:F
Credentials:RDH, ECP III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 TREGO RD
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-5108
Mailing Address - Country:US
Mailing Address - Phone:913-367-6755
Mailing Address - Fax:
Practice Address - Street 1:5222 TREGO RD
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-5108
Practice Address - Country:US
Practice Address - Phone:913-367-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2736124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1013987627Medicaid