Provider Demographics
NPI:1023239902
Name:LUCAS, KELLY W (DDS)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:W
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 1:3161 E PALMER-WASILLA HWY
Mailing Address - Street 2:REGAN BLDG SU 5
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7271
Mailing Address - Country:US
Mailing Address - Phone:907-357-5214
Mailing Address - Fax:907-357-5213
Practice Address - Street 1:2 SCHOOL HOUSE RD
Practice Address - Street 2:
Practice Address - City:NAKNEK
Practice Address - State:AK
Practice Address - Zip Code:99633
Practice Address - Country:US
Practice Address - Phone:907-357-5214
Practice Address - Fax:907-357-5213
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA673122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0673Medicaid