Provider Demographics
NPI:1912345042
Name:LUCKING, KATHLEEN MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:LUCKING
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 1:5400 CORACI BLVD APT 6102
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7576
Mailing Address - Country:US
Mailing Address - Phone:989-708-1384
Mailing Address - Fax:
Practice Address - Street 1:5400 CORACI BLVD APT 6102
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-7576
Practice Address - Country:US
Practice Address - Phone:989-708-1384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029445122300000X
390200000X
FLDN24377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14430849Medicaid