Healthcare Provider Details

I. General information

NPI: 1760378160
Provider Name (Legal Business Name): PHAT-LUCAS VO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 GROOM RD
BAKER LA
70714-3402
US

IV. Provider business mailing address

3114 GROOM RD
BAKER LA
70714-3402
US

V. Phone/Fax

Practice location:
  • Phone: 225-775-0160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7656
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD.007460-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: