Provider Demographics
NPI:1588845416
Name:MARK TWICHELL & ANNETTE LUKASIK DDS LLP
Entity Type:Organization
Organization Name:MARK TWICHELL & ANNETTE LUKASIK DDS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:TWICHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-672-2854
Mailing Address - Street 1:85 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063
Mailing Address - Country:US
Mailing Address - Phone:716-672-2854
Mailing Address - Fax:716-672-5269
Practice Address - Street 1:85 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063
Practice Address - Country:US
Practice Address - Phone:716-672-2854
Practice Address - Fax:716-672-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04565611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01549233Medicaid
NY02881670Medicaid