Provider Demographics
NPI:1861126070
Name:VAN WIE, LUCAS (DDS)
Entity type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:
Last Name:VAN WIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 KUESTER LK
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-8609
Mailing Address - Country:US
Mailing Address - Phone:308-390-5067
Mailing Address - Fax:
Practice Address - Street 1:2773 B 1/2 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81503-3036
Practice Address - Country:US
Practice Address - Phone:970-257-1103
Practice Address - Fax:970-257-7522
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002052441223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice