Provider Demographics
NPI:1104984178
Name:LUCACHICK, GARY ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROBERT
Last Name:LUCACHICK
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 1:501 3RD ST
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2305
Mailing Address - Country:US
Mailing Address - Phone:218-285-7822
Mailing Address - Fax:218-285-7822
Practice Address - Street 1:501 3RD ST
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2305
Practice Address - Country:US
Practice Address - Phone:218-285-7822
Practice Address - Fax:218-285-7822
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice