Provider Demographics
NPI:1659654564
Name:LUCERO DDS INC PC
Entity Type:Organization
Organization Name:LUCERO DDS INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:JUAN
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-599-5980
Mailing Address - Street 1:1855 AUSTIN BLUFFS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-7880
Mailing Address - Country:US
Mailing Address - Phone:719-599-5980
Mailing Address - Fax:719-599-0691
Practice Address - Street 1:1855 AUSTIN BLUFFS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-7880
Practice Address - Country:US
Practice Address - Phone:719-599-5980
Practice Address - Fax:719-599-0691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02000800Medicaid
CO04017570Medicaid
CO02072908Medicaid