Provider Demographics
NPI:1285843060
Name:LUCKS MILLER, HEATHER L (DDS)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:L
Last Name:LUCKS MILLER
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:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0785
Mailing Address - Country:US
Mailing Address - Phone:631-751-2636
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BUILDING 10 SUITE 38
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-751-2636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046628-11223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics