Provider Demographics
NPI:1386051993
Name:KAREN BRYANT LUCKETT,DMD,PLLC
Entity type:Organization
Organization Name:KAREN BRYANT LUCKETT,DMD,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-684-3966
Mailing Address - Street 1:1121B DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3829
Mailing Address - Country:US
Mailing Address - Phone:601-684-3966
Mailing Address - Fax:601-684-3875
Practice Address - Street 1:1121B DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3829
Practice Address - Country:US
Practice Address - Phone:601-684-3966
Practice Address - Fax:601-684-3875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2664-92261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660074Medicaid