MEDICARE: LUCACHICK DENTAL OFFICE, P.A.

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1346307394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCACHICK DENTAL OFFICE, P.A.

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	:	OWNER DENTIST PRESIDENT
Name	:	DR. GARY ROBERT LUCACHICK
Credential	:	D.D.S.
Telephone Number	:	218-285-7822

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	08/22/2020

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