Provider Demographics
NPI:1508298019
Name:TUCKER, BRADLEY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WILLIAM
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 1:940 BLACK CANYON WAY
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-9833
Mailing Address - Country:US
Mailing Address - Phone:360-820-1407
Mailing Address - Fax:
Practice Address - Street 1:940 BLACK CANYON WAY
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81403-9833
Practice Address - Country:US
Practice Address - Phone:360-820-1407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist