Healthcare Provider Details

I. General information

NPI: 1992155659
Provider Name (Legal Business Name): LUCAS MCSHOSH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY STREET SE HEART OF THE CITY HEALTH CENTER
GRAND RAPIDS MI
49503-4130
US

IV. Provider business mailing address

1003 N LAFAYETTE ST
GREENVILLE MI
48838-1168
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021828
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: