Basic Information
| Provider Information | |||||||||
| NPI: | 1841585593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 E BONNEVILLE AVE UNIT 720 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891016662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192108901 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8931 SE FOSTER RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972664661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2011 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | D9930 | OR | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | S6-195C | NV | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.