Provider Demographics
NPI:1861655417
Name:LUCERO, MARTHA R (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:R
Last Name:LUCERO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12833 HARBOR BLVD
Mailing Address - Street 2:SUITE F-3
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5806
Mailing Address - Country:US
Mailing Address - Phone:714-534-9480
Mailing Address - Fax:714-534-9482
Practice Address - Street 1:12833 HARBOR BLVD
Practice Address - Street 2:SUITE F-3
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-5806
Practice Address - Country:US
Practice Address - Phone:714-534-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35947122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist