Provider Demographics
NPI:1427022441
Name:TUCKER, MYRON R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:R
Last Name:TUCKER
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 1:411 BILLINGSLEY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1066
Mailing Address - Country:US
Mailing Address - Phone:704-347-3900
Mailing Address - Fax:704-347-0133
Practice Address - Street 1:411 BILLINGSLEY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1066
Practice Address - Country:US
Practice Address - Phone:704-347-3900
Practice Address - Fax:704-347-0133
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899853BMedicaid
NC9853BOtherBCBS
NCT91796Medicare UPIN
NC899853BMedicaid