Provider Demographics
NPI:1891248118
Name:LUCILLE DENTAL,LLC
Entity Type:Organization
Organization Name:LUCILLE DENTAL,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:GURR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-353-0027
Mailing Address - Street 1:110 E SWANSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7024
Mailing Address - Country:US
Mailing Address - Phone:907-376-5207
Mailing Address - Fax:
Practice Address - Street 1:110 E SWANSON AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7024
Practice Address - Country:US
Practice Address - Phone:907-376-5207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10402521223G0001X
124Q00000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty