Provider Demographics
NPI:1174500755
Name:LUCERO, MARY ANN (DDS)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:LUCERO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 LOUISIANA BLVD NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4546
Mailing Address - Country:US
Mailing Address - Phone:505-883-4867
Mailing Address - Fax:505-883-4007
Practice Address - Street 1:2201 LOUISIANA BLVD
Practice Address - Street 2:STE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-883-4867
Practice Address - Fax:505-883-4007
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1879122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDD1879OtherDENTAL LICENSE