Provider Demographics
NPI:1356861827
Name:SMITH, TUCKER COLIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TUCKER
Middle Name:COLIN
Last Name:SMITH
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 1:624 FOX HOLW
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2391
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5898 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-8714
Practice Address - Country:US
Practice Address - Phone:608-849-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001607-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice