MEDICARE: MICHAEL A. LUCKETT, DMD & ASSOCIATES (WESTERN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223E0200X	Endodontics
3	1223P0221X	Pediatric Dentistry
4	1223P0300X	Periodontics
5	1223P0700X	Prosthodontics
6	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
7	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1831169218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL A. LUCKETT, DMD & ASSOCIATES (WESTERN

Provider Business Mailing Address
First Line	:	17300 DALLAS PARKWAY #1070
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248
Country	:	US
Telephone Number	:	972-755-0880
Fax Number	:	972-755-0890

Provider Business Practice Location Address
First Line	:	6153 SOUTH WESTERN AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636
Country	:	US
Telephone Number	:	773-863-0129
Fax Number	:	216-584-1064

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. MICHAEL LUCKETT
Credential	:	DMD
Telephone Number	:	773-863-0129

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	12/28/2011

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