Provider Demographics
NPI:1336314400
Name:STUCKER, DERIK E (DDS)
Entity Type:Individual
Prefix:
First Name:DERIK
Middle Name:E
Last Name:STUCKER
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 1:1037 MAIN ST
Mailing Address - Street 2:HUDSON RIVER HEALTHCARE, INC.
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2913
Mailing Address - Country:US
Mailing Address - Phone:914-734-8800
Mailing Address - Fax:845-373-7021
Practice Address - Street 1:3360 ROUTE 343
Practice Address - Street 2:HUDSON RIVER HEALTHCARE, INC.
Practice Address - City:AMENIA
Practice Address - State:NY
Practice Address - Zip Code:12501-5619
Practice Address - Country:US
Practice Address - Phone:845-838-7038
Practice Address - Fax:845-373-7021
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMTD-00-19122300000X
NY054444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03541646Medicaid