Provider Demographics
NPI:1821104621
Name:LUCKETT, KAREN BRYANT (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:BRYANT
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 DELAWARE AVENUE
Mailing Address - Street 2:B
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-684-3966
Mailing Address - Fax:601-684-3875
Practice Address - Street 1:1121 DELAWARE AVENUE
Practice Address - Street 2:B
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-684-3966
Practice Address - Fax:601-684-3875
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2664921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1891231OtherMEDICAID
MS00660074Medicaid
834997OtherUNITED CONCORDIA