Provider Demographics
NPI:1922018050
Name:DRAPER DENTAL PC
Entity Type:Organization
Organization Name:DRAPER DENTAL PC
Other - Org Name:ROBERT M LUCERO
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-553-9824
Mailing Address - Street 1:668 E 12225 S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8340
Mailing Address - Country:US
Mailing Address - Phone:801-553-9824
Mailing Address - Fax:801-553-0471
Practice Address - Street 1:668 E 12225 S
Practice Address - Street 2:SUITE 101
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8340
Practice Address - Country:US
Practice Address - Phone:801-553-9824
Practice Address - Fax:801-553-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT279701-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
783866OtherUNITED CONCORDIA