Provider Demographics
NPI:1780654202
Name:LUTCHKA, BRADLEY J
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:LUTCHKA
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 1:930 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-797-1770
Mailing Address - Fax:309-797-1791
Practice Address - Street 1:930 16TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-797-1770
Practice Address - Fax:309-797-1791
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F89740Medicare UPIN
395680Medicare ID - Type Unspecified