Provider Demographics
NPI:1053444141
Name:LUKASIK, MARY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:LUKASIK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:LUKASIK-MOSIG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1815 VIA EL PRADO STE 400
Mailing Address - Street 2:HOLLYWOOD RIVIERA VILLAGE
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5727
Mailing Address - Country:US
Mailing Address - Phone:310-792-4325
Mailing Address - Fax:310-792-4328
Practice Address - Street 1:1815 VIA EL PRADO STE 400
Practice Address - Street 2:HOLLYWOOD RIVIERA VILLAGE
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5727
Practice Address - Country:US
Practice Address - Phone:310-792-4325
Practice Address - Fax:310-792-4328
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice