MEDICARE: DR. JASON WAYNE LUCAS D.M.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	1223G0001X	General Practice Dentistry	DN013726	GA

General Provider Information

NPI Number	:	1790946622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON WAYNE LUCAS D.M.D

Provider Business Mailing Address
First Line	:	1600 ALICE ST
Second Line	:
City	:	WAYCROSS
State	:	GA
Zip	:	31501-4533
Country	:	US
Telephone Number	:	912-285-3140
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 ALICE ST
Second Line	:
City	:	WAYCROSS
State	:	GA
Zip	:	31501-4533
Country	:	US
Telephone Number	:	912-285-3140
Fax Number	:

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

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	06/23/2008

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