Individual
DR. LACEDRIC REITRICH TOLLIVER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
1501 HANDLEY DR, FORT WORTH, TX 76112-3328
(817) 457-4141
Mailing address
2502 RIVERSIDE PKWY, APT 1324, GRAND PRAIRIE, TX 75050-7969
(617) 717-4487
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
25725
TX
Other
Enumeration date
08/02/2010
Last updated
08/11/2010
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