Healthcare Provider Details

I. General information

NPI: 1811985567
Provider Name (Legal Business Name): DR. LUCAS GATES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIN ST
ORANGE CA
92868-4525
US

IV. Provider business mailing address

301 GIBSON DR APT 423
ROSEVILLE CA
95678-5402
US

V. Phone/Fax

Practice location:
  • Phone: 714-571-5688
  • Fax:
Mailing address:
  • Phone: 805-345-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: