MEDICARE: DR. GARY ROBERT LUCACHICK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	9747	MN

General Provider Information

NPI Number	:	1104984178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ROBERT LUCACHICK D.D.S.

Provider Business Mailing Address
First Line	:	501 3RD ST
Second Line	:
City	:	INTERNATIONAL FALLS
State	:	MN
Zip	:	56649-2305
Country	:	US
Telephone Number	:	218-285-7822
Fax Number	:	218-285-7822

Provider Business Practice Location Address
First Line	:	501 3RD ST
Second Line	:
City	:	INTERNATIONAL FALLS
State	:	MN
Zip	:	56649-2305
Country	:	US
Telephone Number	:	218-285-7822
Fax Number	:	218-285-7822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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