Healthcare Provider Details

I. General information

NPI: 1548242597
Provider Name (Legal Business Name): W CHARLES MCLUCKIE DDS MS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 NATIONAL HWY
LAVALE MD
21502-7129
US

IV. Provider business mailing address

428 NATIONAL HWY
LAVALE MD
21502-7129
US

V. Phone/Fax

Practice location:
  • Phone: 301-722-5850
  • Fax: 301-722-4960
Mailing address:
  • Phone: 301-722-5850
  • Fax: 301-722-4960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13543
License Number StateMD

VIII. Authorized Official

Name: JAMES ROBERT SNODGRASS
Title or Position: ORTHODONTIST PRESIDENT
Credential: DDS
Phone: 301-722-5850