Provider Demographics
NPI:1417135625
Name:CRYSTAL FALLS FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:CRYSTAL FALLS FAMILY DENTISTRY, PLLC
Other - Org Name:TUCKER FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-260-9333
Mailing Address - Street 1:10703 E CRYSTAL FALLS PKWY
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-2259
Mailing Address - Country:US
Mailing Address - Phone:512-260-9333
Mailing Address - Fax:512-260-9331
Practice Address - Street 1:10703 E CRYSTAL FALLS PKWY
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-2259
Practice Address - Country:US
Practice Address - Phone:512-260-9333
Practice Address - Fax:512-260-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22102261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental