Provider Demographics
NPI:1588941298
Name:VON LACKUM, NANCY KATHERINE (DMD, PHD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:KATHERINE
Last Name:VON LACKUM
Suffix:
Gender:F
Credentials:DMD, PHD
Other - Prefix:DR
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:VON LACKUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD, PHD
Mailing Address - Street 1:620 PERIMETER DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4125
Mailing Address - Country:US
Mailing Address - Phone:859-268-1596
Mailing Address - Fax:859-977-7376
Practice Address - Street 1:620 PERIMETER DR
Practice Address - Street 2:SUITE 103
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4125
Practice Address - Country:US
Practice Address - Phone:859-268-1596
Practice Address - Fax:859-977-7376
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9105122300000X
KY9231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist