Healthcare Provider Details

I. General information

NPI: 1982724092
Provider Name (Legal Business Name): EDWARD E. LUCAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 01/20/2024
Certification Date: 01/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2961 RIVERMEADE DR NW
ATLANTA GA
30327-2039
US

IV. Provider business mailing address

2961 RIVERMEADE DR NW
ATLANTA GA
30327-2039
US

V. Phone/Fax

Practice location:
  • Phone: 404-313-1243
  • Fax:
Mailing address:
  • Phone: 404-313-1243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN007894
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: