Provider Demographics
NPI:1144219643
Name:TUCKER, STEVEN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:R
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SOMERSLY PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5717
Mailing Address - Country:US
Mailing Address - Phone:270-485-2762
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST STE D214A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-6048
Practice Address - Country:US
Practice Address - Phone:270-485-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4475204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60044757Medicaid
KY000000208416OtherBCBS
KY64044753Medicaid
KY65912016Medicaid
KY60044757Medicaid
KY65912016Medicaid