Provider Demographics
NPI:1235392390
Name:LUCK DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:LUCK DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-472-2211
Mailing Address - Street 1:308 N 1ST ST
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-9087
Mailing Address - Country:US
Mailing Address - Phone:715-472-2211
Mailing Address - Fax:715-472-4485
Practice Address - Street 1:308 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LUCK
Practice Address - State:WI
Practice Address - Zip Code:54853-9087
Practice Address - Country:US
Practice Address - Phone:715-472-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50012231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33571700Medicaid