Healthcare Provider Details

I. General information

NPI: 1831169218
Provider Name (Legal Business Name): MICHAEL A. LUCKETT, DMD & ASSOCIATES (WESTERN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6153 SOUTH WESTERN AVENUE
CHICAGO IL
60636
US

IV. Provider business mailing address

17300 DALLAS PARKWAY #1070
DALLAS TX
75248
US

V. Phone/Fax

Practice location:
  • Phone: 773-863-0129
  • Fax: 216-584-1064
Mailing address:
  • Phone: 972-755-0880
  • Fax: 972-755-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL LUCKETT
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 773-863-0129