Healthcare Provider Details

I. General information

NPI: 1316873821
Provider Name (Legal Business Name): TRISTAN GRANT LUCKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 JOHNSTOWN RD
BECKLEY WV
25801-4942
US

IV. Provider business mailing address

832 BROAD ST
SUMMERSVILLE WV
26651-1758
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-0717
  • Fax:
Mailing address:
  • Phone: 304-644-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4872
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: