Provider Demographics
NPI:1053952796
Name:LUCAS-PERRY, LAVAL ALONZO (RDH)
Entity type:Individual
Prefix:MR
First Name:LAVAL
Middle Name:ALONZO
Last Name:LUCAS-PERRY
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4494 WARWICK CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8337
Mailing Address - Country:US
Mailing Address - Phone:810-691-0245
Mailing Address - Fax:
Practice Address - Street 1:4727 SAINT ANTOINE ST STE 408
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-833-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902018904124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist