MEDICARE: DR. PERCY EDGAR LUECKE III D.D.S., M.S.D.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	15344	TX

General Provider Information

NPI Number	:	1477766061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PERCY EDGAR LUECKE III D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	4902 GOLDEN QUAIL
Second Line	:	SUITE 100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-1636
Country	:	US
Telephone Number	:	210-690-0662
Fax Number	:	210-696-8742

Provider Business Practice Location Address
First Line	:	4902 GOLDEN QUAIL
Second Line	:	SUITE 100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-1636
Country	:	US
Telephone Number	:	210-690-0662
Fax Number	:	210-696-8742

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	04/11/2011

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