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General NPI Number Information
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NPI Number | 1053952796
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Entity Type | Individual
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Provider Name | LAVAL ALONZO LUCAS-PERRY RDH
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Gender | Male
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Dates
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Enumeration Date | 10/03/2019
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Last Update Date | 10/03/2019
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Provider Practice Location Address
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Address Line | 4727 SAINT ANTOINE ST STE 408
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City | DETROIT
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State | MI
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Zip | 48201-1461
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Country | US
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Telephone | 313-833-7309
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Fax |
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Provider Business Mailing Address
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Address Line | 4494 WARWICK CIRCLE DR
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City | GRAND BLANC
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State | MI
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Zip | 48439-8337
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Country | US
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Telephone | 810-691-0245
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 2902018904
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License Number State | MI
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