Provider Demographics
NPI:1326095159
Name:MIKE A. LUTZ, D.D.S., P.C.
Entity Type:Organization
Organization Name:MIKE A. LUTZ, D.D.S., P.C.
Other - Org Name:LUTZ & STENQUIST, D.D.S., P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-796-8686
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018-0130
Mailing Address - Country:US
Mailing Address - Phone:573-796-8686
Mailing Address - Fax:573-796-5050
Practice Address - Street 1:1021 W BUCHANAN ST
Practice Address - Street 2:SUITE 18
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1238
Practice Address - Country:US
Practice Address - Phone:573-796-8686
Practice Address - Fax:573-796-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO148951223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty