Basic Information
| Provider Information | |||||||||
| NPI: | 1023070448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUTKA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DENTAC 2410 STANLEY ROAD | ||||||||
| Address2: | SUITE 200J | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782346230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102952743 | ||||||||
| FaxNumber: | 2102952602 | ||||||||
| Practice Location | |||||||||
| Address1: | DENTAC 2410 STANLEY ROAD | ||||||||
| Address2: | SUITE 200J | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782346230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102952743 | ||||||||
| FaxNumber: | 2102952602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DS023023L | PA | Y | Dental Providers | Dentist | General Practice |
No ID Information.