Healthcare Provider Details

I. General information

NPI: 1154414456
Provider Name (Legal Business Name): FRED R LUCAS DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N NASH
WATONGA OK
73772-0570
US

IV. Provider business mailing address

PO BOX 570
WATONGA OK
73772-0570
US

V. Phone/Fax

Practice location:
  • Phone: 580-623-7397
  • Fax: 580-623-4912
Mailing address:
  • Phone: 580-623-7397
  • Fax: 580-623-4912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. FRED R LUCAS JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 580-623-7397