=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245683804
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL E LUKAVSKY DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2016
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NM-571 #28
-----------------------------------------------------
City | EL RITO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-581-0028
-----------------------------------------------------
Fax | 575-581-4592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | NM-571 #28
-----------------------------------------------------
City | EL RITO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-581-0028
-----------------------------------------------------
Fax | 575-581-4592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D009556
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4778
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------