Provider Demographics
NPI:1831784339
Name:LUSK, BRIAN GREGORY (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GREGORY
Last Name:LUSK
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 1:18 FORT WARREN AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-8265
Mailing Address - Country:US
Mailing Address - Phone:304-923-7930
Mailing Address - Fax:
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-2945
Practice Address - Country:US
Practice Address - Phone:307-773-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV45171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program