Provider Demographics
NPI:1396184693
Name:THE DENTIST OFF MAIN, PLLC
Entity Type:Organization
Organization Name:THE DENTIST OFF MAIN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:LUCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:817-527-1590
Mailing Address - Street 1:1245 S. MAIN ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051
Mailing Address - Country:US
Mailing Address - Phone:817-527-1590
Mailing Address - Fax:940-497-3010
Practice Address - Street 1:1245 S. MAIN ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-527-1590
Practice Address - Fax:940-497-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
870515OtherUNITED CONCORDIA