Provider Demographics
NPI:1700046232
Name:LUCERO, PERRY GERARD
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:GERARD
Last Name:LUCERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-4917
Mailing Address - Country:US
Mailing Address - Phone:909-593-4628
Mailing Address - Fax:909-593-4125
Practice Address - Street 1:2210 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-4917
Practice Address - Country:US
Practice Address - Phone:909-593-4628
Practice Address - Fax:909-593-4125
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA034374122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist