Provider Demographics
NPI:1245676295
Name:LUCAS, COLLETTE T (DDS)
Entity type:Individual
Prefix:
First Name:COLLETTE
Middle Name:T
Last Name:LUCAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 FOUNTAIN PL
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1202
Mailing Address - Country:US
Mailing Address - Phone:636-273-9258
Mailing Address - Fax:636-273-3710
Practice Address - Street 1:2751 FOUNTAIN PL
Practice Address - Street 2:SUITE 1
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1202
Practice Address - Country:US
Practice Address - Phone:636-273-9258
Practice Address - Fax:636-273-3710
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist