MEDICARE: MALLORY LUTZ 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	1223G0001X	General Practice Dentistry	30.027517	OH

General Provider Information

NPI Number	:	1851140628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY LUTZ DDS

Provider Business Mailing Address
First Line	:	800 E WAYNE ST
Second Line	:
City	:	CELINA
State	:	OH
Zip	:	45822-1359
Country	:	US
Telephone Number	:	419-586-1615
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E WAYNE ST
Second Line	:
City	:	CELINA
State	:	OH
Zip	:	45822-1359
Country	:	US
Telephone Number	:	419-586-1615
Fax Number	:

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

Provider Enumeration Date	:	05/15/2024
Last Update Date	:	05/28/2026

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1801727276 — ALIVYA RAE BAKLE
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Directions to “ MALLORY LUTZ DDS” Practice Location

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