Provider Demographics
NPI:1528208568
Name:LUCZAK, RICHARD BERNARD (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BERNARD
Last Name:LUCZAK
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7522
Mailing Address - Country:US
Mailing Address - Phone:817-527-1590
Mailing Address - Fax:817-416-8431
Practice Address - Street 1:1245 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7522
Practice Address - Country:US
Practice Address - Phone:817-527-1590
Practice Address - Fax:817-416-8431
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
870515OtherUNITED CONCORDIA