Provider Demographics
NPI:1215360110
Name:LUKIS, KEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:LUKIS
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 1:1250 FOREST AVE STE 3B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1889
Mailing Address - Country:US
Mailing Address - Phone:207-878-3480
Mailing Address - Fax:
Practice Address - Street 1:1250 FOREST AVE
Practice Address - Street 2:STE 3B
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1889
Practice Address - Country:US
Practice Address - Phone:207-878-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME43211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME4321OtherDENTAL LICENSE NUMBER