Provider Demographics
NPI:1003224833
Name:LUCKETT, STEPHANIE N (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:N
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2215 PORTLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40242-3214
Mailing Address - Country:US
Mailing Address - Phone:502-772-8160
Mailing Address - Fax:502-772-8108
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-772-8160
Practice Address - Fax:502-772-8108
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9477122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist