Provider Demographics
NPI:1174080162
Name:TUCKER, TRACEY S (DDS)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:S
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6274 BAYWATER LN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083-9768
Mailing Address - Country:US
Mailing Address - Phone:269-366-0909
Mailing Address - Fax:
Practice Address - Street 1:6274 BAYWATER LN
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9768
Practice Address - Country:US
Practice Address - Phone:269-366-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010170721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice