Healthcare Provider Details

I. General information

NPI: 1740834852
Provider Name (Legal Business Name): LUKE AVERETT FACER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14415 CULVER DR
IRVINE CA
92604-0305
US

IV. Provider business mailing address

27012 FLORESTA LN
MISSION VIEJO CA
92691-5203
US

V. Phone/Fax

Practice location:
  • Phone: 949-733-0486
  • Fax:
Mailing address:
  • Phone: 949-422-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60975999
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: