Provider Demographics
NPI:1174594378
Name:MICHAEL A. LUCKETT D.M.D. & ASSOCIATES (RIVERCREST), LTD.
Entity type:Organization
Organization Name:MICHAEL A. LUCKETT D.M.D. & ASSOCIATES (RIVERCREST), LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-597-9055
Mailing Address - Street 1:PO BOX 860036
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486
Mailing Address - Country:US
Mailing Address - Phone:216-584-1000
Mailing Address - Fax:216-332-7503
Practice Address - Street 1:4839 WEST CALSAG RD
Practice Address - Street 2:#310
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-4415
Practice Address - Country:US
Practice Address - Phone:708-597-9055
Practice Address - Fax:216-584-1062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTALONE PARTNERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-27
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223E0200X, 1223P0221X, 1223P0300X, 1223P0700X, 1223X0400X
IL019.0198351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty