Provider Demographics
NPI:1114555448
Name:LUCHETTI, JEFFREY MICHAEL
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:LUCHETTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8305 FALLS OF NEUSE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3546
Mailing Address - Country:US
Mailing Address - Phone:717-576-0372
Mailing Address - Fax:
Practice Address - Street 1:8305 FALLS OF NEUSE RD STE 105
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3546
Practice Address - Country:US
Practice Address - Phone:717-576-0372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12613204E00000X
IL018.002141122300000X
IL019.0329181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery