Basic Information
| Provider Information | |||||||||
| NPI: | 1154765980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCKENBILL | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 PENTAGON BLVD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454311705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374335309 | ||||||||
| FaxNumber: | 9372980287 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 PENTAGON BLVD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454311705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374335309 | ||||||||
| FaxNumber: | 9372980287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2013 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 35.136839 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0370542 | 05 | OH | MEDICAID |