Healthcare Provider Details

I. General information

NPI: 1306343306
Provider Name (Legal Business Name): JONATHAN THACHARA LUKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2018
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26220 POINT LOOKOUT RD
LEONARDTOWN MD
20650-3748
US

IV. Provider business mailing address

PO BOX 477, 26220 POINT LOOKOUT ROAD
LEONARDTOWN MD
20650-2158
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-8100
  • Fax:
Mailing address:
  • Phone: 301-475-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16580
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS042595
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: