Provider Demographics
NPI:1710367636
Name:CASTRO, LUCIANA
Entity Type:Individual
Prefix:
First Name:LUCIANA
Middle Name:
Last Name:CASTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 ORCHARDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11745 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9219
Practice Address - Country:US
Practice Address - Phone:517-522-5018
Practice Address - Fax:517-522-3708
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010212711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice