Provider Demographics
NPI:1912019522
Name:LUCAS, MARK WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:LUCAS
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 1:6067 BROOKSTONE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9432
Mailing Address - Country:US
Mailing Address - Phone:810-695-6780
Mailing Address - Fax:
Practice Address - Street 1:4170 LENNON RD
Practice Address - Street 2:SUITE C
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1083
Practice Address - Country:US
Practice Address - Phone:810-732-0303
Practice Address - Fax:810-732-1360
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010132731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice