Provider Demographics
NPI:1942420674
Name:K. JARED LUSK DDS P.C.
Entity Type:Organization
Organization Name:K. JARED LUSK DDS P.C.
Other - Org Name:LUSK FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:K.
Authorized Official - Middle Name:JARED
Authorized Official - Last Name:LUSK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-325-8401
Mailing Address - Street 1:204 N AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8412
Mailing Address - Country:US
Mailing Address - Phone:505-325-8401
Mailing Address - Fax:505-325-8705
Practice Address - Street 1:204 N AUBURN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8412
Practice Address - Country:US
Practice Address - Phone:505-325-8401
Practice Address - Fax:505-325-8705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM891069OtherUNITED CONCORDIA
NMNM008392OtherBLUECROSS BLUESHIELD