1275630923 NPI number — LUCAS-PERRY DENTAL GROUP, P.L.L.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275630923 NPI number — LUCAS-PERRY DENTAL GROUP, P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUCAS-PERRY DENTAL GROUP, P.L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275630923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4494 WARWICK CIRCLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-8337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-695-6621
Provider Business Mailing Address Fax Number:
810-695-6728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4160 JOHN R ST
Provider Second Line Business Practice Location Address:
SUITE 824
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-691-2268
Provider Business Practice Location Address Fax Number:
810-695-6728
Provider Enumeration Date:
09/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUCAS
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-691-2268

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901013084 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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