Provider Demographics
NPI:1578377917
Name:BRENNEIS, LACIE R (RDH)
Entity type:Individual
Prefix:MS
First Name:LACIE
Middle Name:R
Last Name:BRENNEIS
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 1:234 TISINGER ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT JACKSON
Mailing Address - State:VA
Mailing Address - Zip Code:22842-9306
Mailing Address - Country:US
Mailing Address - Phone:757-515-5785
Mailing Address - Fax:
Practice Address - Street 1:124 VALLEY VISTA DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1608
Practice Address - Country:US
Practice Address - Phone:540-459-9333
Practice Address - Fax:540-459-1809
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207648124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist