Provider Demographics
NPI:1316780422
Name:TUCKER, SHAVON (DDS)
Entity type:Individual
Prefix:DR
First Name:SHAVON
Middle Name:
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 1:2555 N DR MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2709
Mailing Address - Country:US
Mailing Address - Phone:414-267-2670
Mailing Address - Fax:414-562-8432
Practice Address - Street 1:2555 N DR MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-267-2670
Practice Address - Fax:414-562-8432
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024022265122300000X
WI6001651-151223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice