Healthcare Provider Details

I. General information

NPI: 1710367636
Provider Name (Legal Business Name): LUCIANA CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11745 E MICHIGAN AVE
GRASS LAKE MI
49240-9219
US

IV. Provider business mailing address

2143 ORCHARDVIEW DR
ANN ARBOR MI
48108
US

V. Phone/Fax

Practice location:
  • Phone: 517-522-5018
  • Fax: 517-522-3708
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901021271
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: