Basic Information
| Provider Information | |||||||||
| NPI: | 1053373175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ISAAC | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 STANLEY ROAD | ||||||||
| Address2: | DENTAC SUITE 200J | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782346230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102952743 | ||||||||
| FaxNumber: | 2102952602 | ||||||||
| Practice Location | |||||||||
| Address1: | 2410 STANLEY ROAD | ||||||||
| Address2: | DENTAC SUITE 200J | ||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782346230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102952743 | ||||||||
| FaxNumber: | 2102952602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0021380 | TX | N | Dental Providers | Dentist | General Practice | 1223S0112X | 21380 | TX | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.