MEDICARE: DR. KATHLEEN MARIE LUCKING D.D.S.

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	019029445	IL
2	390200000X	Student in an Organized Health Care Education/Training Program
3	122300000X	Dentist	DN24377	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912345042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN MARIE LUCKING D.D.S.

Provider Business Mailing Address
First Line	:	5400 CORACI BLVD APT 6102
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-7576
Country	:	US
Telephone Number	:	989-708-1384
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 CORACI BLVD APT 6102
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-7576
Country	:	US
Telephone Number	:	989-708-1384
Fax Number	:

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

Provider Enumeration Date	:	06/11/2013
Last Update Date	:	08/27/2021

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