MEDICARE: LUCZYNSKI DENTAL CORPORATION

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	59349	CA

General Provider Information

NPI Number	:	1386043586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCZYNSKI DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	3531 STERNE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-1845
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3531 STERNE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-1845
Country	:	US
Telephone Number	:	619-794-4965
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	DR. PAUL LUCZYNSKI
Credential	:	DDS
Telephone Number	:	619-794-4965

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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