Provider Demographics
NPI:1194141895
Name:LUCKETT, BRANDON CURTIS
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:CURTIS
Last Name:LUCKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 CLEARWATER CT
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-1668
Mailing Address - Country:US
Mailing Address - Phone:832-875-2886
Mailing Address - Fax:
Practice Address - Street 1:6540 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-3651
Practice Address - Country:US
Practice Address - Phone:330-758-6165
Practice Address - Fax:330-758-5547
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0596511223X0400X
PADS0436181223X0400X
OH30.0260801223X0400X
TX308031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics