Provider Demographics
NPI:1710988787
Name:LUCERO, CHARLES JOSEAPH (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEAPH
Last Name:LUCERO
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 1:1751 N STOCKTON HILL RD
Mailing Address - Street 2:STE# A
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6601
Mailing Address - Country:US
Mailing Address - Phone:928-718-8668
Mailing Address - Fax:928-718-2106
Practice Address - Street 1:1751 N STOCKTON HILL RD
Practice Address - Street 2:STE# A
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6601
Practice Address - Country:US
Practice Address - Phone:928-718-8668
Practice Address - Fax:928-718-2106
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
AZD46881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ356601OtherARIZONA PHYSICIANS IPA,