MEDICARE: RICHARD B. LUCZAK, DDS, MPH, PA

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	19398	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	870515	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1245232594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD B. LUCZAK, DDS, MPH, PA

Provider Business Mailing Address
First Line	:	4251 FM 2181
Second Line	:	STE 264
City	:	CORINTH
State	:	TX
Zip	:	76210-4220
Country	:	US
Telephone Number	:	940-497-3000
Fax Number	:	940-497-3010

Provider Business Practice Location Address
First Line	:	4251 FM 2181
Second Line	:	STE 264
City	:	CORINTH
State	:	TX
Zip	:	76210-4220
Country	:	US
Telephone Number	:	940-497-3000
Fax Number	:	940-497-3010

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD BERNARD LUCZAK
Credential	:	DDS, MPH
Telephone Number	:	940-497-3000

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	03/03/2009

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