Provider Demographics
NPI:1619262441
Name:PITLUCK, JOSEPH EDWARD III (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:EDWARD
Last Name:PITLUCK
Suffix:III
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 1:531 HERMOSA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1029
Mailing Address - Country:US
Mailing Address - Phone:303-886-6189
Mailing Address - Fax:
Practice Address - Street 1:4701 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6233
Practice Address - Country:US
Practice Address - Phone:505-232-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice