Provider Demographics
NPI:1235258757
Name:KEVIN C. LUCKY DDS PLLC
Entity Type:Organization
Organization Name:KEVIN C. LUCKY DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:CHARLIE
Authorized Official - Last Name:LUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-872-3919
Mailing Address - Street 1:832 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651
Mailing Address - Country:US
Mailing Address - Phone:304-872-3919
Mailing Address - Fax:304-872-4043
Practice Address - Street 1:1110 JOHNSTOWN ROAD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-0717
Practice Address - Fax:304-255-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104970300OtherINDV. NPI
WV3810007754Medicaid