Healthcare Provider Details

I. General information

NPI: 1891248118
Provider Name (Legal Business Name): LUCILLE DENTAL,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E SWANSON AVE
WASILLA AK
99654-7024
US

IV. Provider business mailing address

110 E SWANSON AVE
WASILLA AK
99654-7024
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-5207
  • Fax:
Mailing address:
  • Phone: 907-376-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1040252
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: KRIS P GURR
Title or Position: OWNER/PRESIDENT
Credential: D.D.S.
Phone: 480-353-0027