Basic Information
| Provider Information | |||||||||
| NPI: | 1114555448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCHETTI | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 GRANDON WAY | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170509124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175760372 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885847888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2020 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 018.002141 | IL | Y | Dental Providers | Dentist |
No ID Information.