Provider Demographics
NPI:1588078224
Name:LUGO, RICARDO (DDS, MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:LUGO
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY RM 530
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6036
Mailing Address - Fax:318-675-6129
Practice Address - Street 1:1501 KINGS HWY RM 530
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6036
Practice Address - Fax:318-675-6129
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS-9911223S0112X
CA630271223S0112X
CAA158305204E00000X
LA311638204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery