Provider Demographics
NPI:1679645733
Name:MACMENAMIN, LUKE JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:JOSEPH
Last Name:MACMENAMIN
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 1:8401 SEASONS PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3414
Mailing Address - Country:US
Mailing Address - Phone:651-738-2341
Mailing Address - Fax:651-738-9048
Practice Address - Street 1:8401 SEASONS PKWY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3414
Practice Address - Country:US
Practice Address - Phone:651-738-2341
Practice Address - Fax:651-738-9048
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33797100Medicaid
V04850Medicare UPIN