Provider Demographics
NPI:1104184936
Name:LUCKENBAUGH, DANIEL ADAM (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ADAM
Last Name:LUCKENBAUGH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18913 JOHN J WILLIAMS HWY
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-4404
Mailing Address - Country:US
Mailing Address - Phone:302-645-6671
Mailing Address - Fax:
Practice Address - Street 1:18913 JOHN J WILLIAMS HWY
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-4404
Practice Address - Country:US
Practice Address - Phone:302-645-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00013301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice