Provider Demographics
NPI:1104970300
Name:LUCKY, KEVIN CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:LUCKY
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 1:832 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651
Mailing Address - Country:US
Mailing Address - Phone:304-872-3919
Mailing Address - Fax:304-872-4943
Practice Address - Street 1:832 BROAD STREET
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651
Practice Address - Country:US
Practice Address - Phone:304-872-3919
Practice Address - Fax:304-872-4943
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134684000Medicaid