Provider Demographics
NPI:1275888257
Name:LUCKMAN, VALENCIA TATANIA (DO)
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:TATANIA
Last Name:LUCKMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 MORAGA AVE
Mailing Address - Street 2:B-206
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5492
Mailing Address - Country:US
Mailing Address - Phone:858-273-0700
Mailing Address - Fax:858-273-8679
Practice Address - Street 1:3737 MORAGA AVE
Practice Address - Street 2:B-206
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5492
Practice Address - Country:US
Practice Address - Phone:858-273-0700
Practice Address - Fax:858-273-8679
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43462122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist