Provider Demographics
NPI:1134290877
Name:LUCKETT, MICHAEL
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4839 CAL SAG RD # 310
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-4415
Mailing Address - Country:US
Mailing Address - Phone:708-597-9055
Mailing Address - Fax:216-584-1062
Practice Address - Street 1:4839 CAL SAG RD # 310
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-4415
Practice Address - Country:US
Practice Address - Phone:708-597-9055
Practice Address - Fax:216-584-7062
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190198351223G0001X
IL019-0198351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice