Provider Demographics
NPI:1821125626
Name:LUCERO, CONRAD PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:PHILLIP
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 1:204 E OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5252
Mailing Address - Country:US
Mailing Address - Phone:909-307-0707
Mailing Address - Fax:909-307-0733
Practice Address - Street 1:204 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5252
Practice Address - Country:US
Practice Address - Phone:909-307-0707
Practice Address - Fax:909-307-0733
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0314911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice