MEDICARE: LUCAS MESDAG DMD

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	122300000X	Dentist	10192	WA

General Provider Information

NPI Number	:	1487790358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCAS MESDAG DMD

Provider Business Mailing Address
First Line	:	1807 COLUMBIA COVE LN S
Second Line	:
City	:	ROCK ISLAND
State	:	WA
Zip	:	98850-9570
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1807 COLUMBIA COVE LN S
Second Line	:
City	:	ROCK ISLAND
State	:	WA
Zip	:	98850-9570
Country	:	US
Telephone Number	:	509-293-2015
Fax Number	:

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/01/2009

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