=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265324644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PELICAN PEDIATRIC DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2025
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 BETH STACEY BLVD UNIT 240
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-6074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-890-8492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 BETH STACEY BLVD UNIT 240
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-6074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. DAVID LUTHER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 925-890-8492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------