Provider Demographics
NPI:1033239744
Name:TUCK, MARTIN J (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
Last Name:TUCK
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:2501 COOLIDGE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6352
Mailing Address - Country:US
Mailing Address - Phone:517-351-0800
Mailing Address - Fax:517-351-3399
Practice Address - Street 1:2501 COOLIDGE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6352
Practice Address - Country:US
Practice Address - Phone:517-351-0800
Practice Address - Fax:517-351-3399
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI29010116411223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901011641OtherLICENSE #
MI1953310700OtherBCBS MEDICAL PIN #