Provider Demographics
NPI:1356572036
Name:SMITH, BRADY TUCKER (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:TUCKER
Last Name:SMITH
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 1:2025 W US HIGHWAY 50
Mailing Address - Street 2:STE A100
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1571
Mailing Address - Country:US
Mailing Address - Phone:719-542-2472
Mailing Address - Fax:719-542-6435
Practice Address - Street 1:2025 W US HIGHWAY 50
Practice Address - Street 2:STE A100
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1571
Practice Address - Country:US
Practice Address - Phone:719-542-2472
Practice Address - Fax:719-542-6435
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice