Provider Demographics
NPI:1962703462
Name:ST. CLAIR, LACEY BRIANNE (RDH)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:BRIANNE
Last Name:ST. CLAIR
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 1:1416 CROWN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:402 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3407
Practice Address - Country:US
Practice Address - Phone:660-665-2741
Practice Address - Fax:660-665-3109
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020510124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist