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General NPI Number Information
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NPI Number | 1306343306
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Entity Type | Individual
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Provider Name | JONATHAN THACHARA LUKE DDS
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Gender | Male
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Dates
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Enumeration Date | 04/07/2018
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Last Update Date | 06/24/2020
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Provider Practice Location Address
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Address Line | 26220 POINT LOOKOUT RD
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City | LEONARDTOWN
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State | MD
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Zip | 20650-3748
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Country | US
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Telephone | 301-475-8100
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 477, 26220 POINT LOOKOUT ROAD
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City | LEONARDTOWN
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State | MD
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Zip | 20650-2158
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Country | US
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Telephone | 301-475-8100
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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 | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DS042595
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16580
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License Number State | MD
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