MEDICARE: MAYLENE LUC DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	51569	CA

General Provider Information

NPI Number	:	1194840017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYLENE LUC DDS

Provider Business Mailing Address
First Line	:	1035 JEFFERSON BLVD
Second Line	:	STE. 7
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-3343
Country	:	US
Telephone Number	:	916-371-9051
Fax Number	:	916-371-9095

Provider Business Practice Location Address
First Line	:	1035 JEFFERSON BLVD
Second Line	:	STE. 7
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-3343
Country	:	US
Telephone Number	:	916-371-9051
Fax Number	:	916-371-9095

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	02/05/2009

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