Healthcare Provider Details

I. General information

NPI: 1356794069
Provider Name (Legal Business Name): LUCCA ORAL AND FACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 DARTMOUTH ST SUITE 403
BOSTON MA
02116-5883
US

IV. Provider business mailing address

185 DARTMOUTH ST SUITE 403
BOSTON MA
02116-5883
US

V. Phone/Fax

Practice location:
  • Phone: 617-300-0345
  • Fax: 617-993-6970
Mailing address:
  • Phone: 617-300-0345
  • Fax: 617-993-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN20676
License Number StateMA

VIII. Authorized Official

Name: MARIO LUCCA
Title or Position: OWNER
Credential: D.M.D.
Phone: 617-300-0345