Provider Demographics
NPI:1245218593
Name:WATES, LUCIUS FRANKLIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LUCIUS
Middle Name:FRANKLIN
Last Name:WATES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 THURGOOD MARSHALL HWY
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-4107
Mailing Address - Country:US
Mailing Address - Phone:843-355-9295
Mailing Address - Fax:843-355-9296
Practice Address - Street 1:509 THURGOOD MARSHALL HWY
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4107
Practice Address - Country:US
Practice Address - Phone:843-355-9295
Practice Address - Fax:843-355-9296
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ19043Medicaid