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Organization
THE DENTIST OFF MAIN, PLLC
Active
Organization
THE DENTIST OFF MAIN, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICHARD BERNARD LUCZAK DDS, MPH (CEO)
(817) 527-1590
Entity
Organization
Contact information
Practice address
1245 S. MAIN ST., SUITE 100, GRAPEVINE, TX 76051
(817) 527-1590
(940) 497-3010
Mailing address
1245 S. MAIN ST., SUITE 100, GRAPEVINE, TX 76051
(817) 527-1590
(940) 497-3010
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
19398
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
870515
UNITED CONCORDIA
—
Enumeration date
06/19/2013
Last updated
06/19/2013
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