Provider Demographics
NPI:1396877551
Name:OTTO, LACI DELEE (RDH)
Entity type:Individual
Prefix:MRS
First Name:LACI
Middle Name:DELEE
Last Name:OTTO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 EAST HWY 3040 APT #1733
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067
Mailing Address - Country:US
Mailing Address - Phone:940-465-1556
Mailing Address - Fax:
Practice Address - Street 1:120 S DENTON TAP RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3297
Practice Address - Country:US
Practice Address - Phone:469-635-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14038124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist