Provider Demographics
NPI:1982010369
Name:LUCAS, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:LUCAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9219 S SUMMER BREEZE LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-6120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:896 S COOK RD
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-7526
Practice Address - Country:US
Practice Address - Phone:928-428-4698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist