Healthcare Provider Details

I. General information

NPI: 1235258757
Provider Name (Legal Business Name): KEVIN C. LUCKY DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 JOHNSTOWN ROAD
BECKLEY WV
25801
US

IV. Provider business mailing address

832 BROAD STREET
SUMMERSVILLE WV
26651
US

V. Phone/Fax

Practice location:
  • Phone: 304-255-0717
  • Fax: 304-255-0956
Mailing address:
  • Phone: 304-872-3919
  • Fax: 304-872-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN CHARLIE LUCKY
Title or Position: OWNER
Credential: DDS
Phone: 304-872-3919