MEDICARE: DR. LUCKANA THERESA ASANDRA D.D.S.

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	12884	MO

General Provider Information

NPI Number	:	1578508156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCKANA THERESA ASANDRA D.D.S.

Provider Business Mailing Address
First Line	:	12A WESTWOODS DR
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-3519
Country	:	US
Telephone Number	:	816-781-0993
Fax Number	:	816-781-0998

Provider Business Practice Location Address
First Line	:	12A WESTWOODS DR
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-3519
Country	:	US
Telephone Number	:	816-781-0993
Fax Number	:	816-781-0998

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

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	07/08/2007

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