Healthcare Provider Details

I. General information

NPI: 1588078224
Provider Name (Legal Business Name): RICARDO LUGO DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY RM 530
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1501 KINGS HWY RM 530
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-6036
  • Fax: 318-675-6129
Mailing address:
  • Phone: 318-675-6036
  • Fax: 318-675-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS-991
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number63027
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA158305
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number311638
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: