Provider Demographics
NPI:1275630923
Name:LUCAS-PERRY DENTAL GROUP, P.L.L.C.
Entity Type:Organization
Organization Name:LUCAS-PERRY DENTAL GROUP, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-691-2268
Mailing Address - Street 1:4494 WARWICK CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8337
Mailing Address - Country:US
Mailing Address - Phone:810-695-6621
Mailing Address - Fax:810-695-6728
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 824
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:810-691-2268
Practice Address - Fax:810-695-6728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010130841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAL30506040OtherDEA #
MI=========OtherUNITED CONCORDIA INS
MI=========OtherDELTA DENTA INS
MI=========OtherAETNADENTAL PPO INS
MI=========OtherFEDERAL TAX ID
MI=========OtherDMO INS
MIAL30506040OtherDEA #
MI=========OtherMETROPOLITIAN LIFE INS