MEDICARE: EVELYN ORA LUCAS-PERRY DDS

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	2901020510	MI

General Provider Information

NPI Number	:	1841616190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELYN ORA LUCAS-PERRY DDS

Provider Business Mailing Address
First Line	:	4494 WARWICK CIRCLE DR
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8337
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4494 WARWICK CIRCLE DR
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8337
Country	:	US
Telephone Number	:	810-691-2869
Fax Number	:

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

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	03/11/2014

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