Healthcare Provider Details

I. General information

NPI: 1558425082
Provider Name (Legal Business Name): MICHAEL H DELUCA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5123 W ST JOE HWY SUITE 101
LANSING MI
48917-4093
US

IV. Provider business mailing address

5123 W ST JOE HWY SUITE 101
LANSING MI
48917-4093
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-4254
  • Fax: 517-321-0729
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10115
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: