Provider Demographics
NPI:1467519868
Name:LUSCH, ROY CREAGER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:CREAGER
Last Name:LUSCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SE 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3965
Mailing Address - Country:US
Mailing Address - Phone:503-863-4048
Mailing Address - Fax:
Practice Address - Street 1:948 NE 102ND AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4064
Practice Address - Country:US
Practice Address - Phone:503-253-1109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930943902OtherTAX ID