Provider Demographics
NPI:1710072772
Name:ANGELO LUCKETT DDS PC
Entity Type:Organization
Organization Name:ANGELO LUCKETT DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-423-2286
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:245 MAIN STREET
Mailing Address - City:KREBS
Mailing Address - State:OK
Mailing Address - Zip Code:74554
Mailing Address - Country:US
Mailing Address - Phone:918-423-2286
Mailing Address - Fax:918-423-3506
Practice Address - Street 1:245 MAIN STREET
Practice Address - Street 2:245 MAIN STREET
Practice Address - City:KREBS
Practice Address - State:OK
Practice Address - Zip Code:74554
Practice Address - Country:US
Practice Address - Phone:918-423-2286
Practice Address - Fax:918-423-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty