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General NPI Number Information
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NPI Number | 1316873821
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Entity Type | Individual
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Provider Name | TRISTAN GRANT LUCKY
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Gender | Male
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Dates
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Enumeration Date | 06/22/2026
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Last Update Date | 06/22/2026
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Provider Practice Location Address
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Address Line | 1110 JOHNSTOWN RD
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City | BECKLEY
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State | WV
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Zip | 25801-4942
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Country | US
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Telephone | 304-255-0717
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Fax |
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Provider Business Mailing Address
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Address Line | 832 BROAD ST
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1758
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Country | US
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Telephone | 304-644-5382
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4872
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License Number State | WV
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