Provider Demographics
NPI:1548788631
Name:BETTY TUCKER, D.D.S., LLC
Entity Type:Organization
Organization Name:BETTY TUCKER, D.D.S., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:HUANG
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:419-463-0023
Mailing Address - Street 1:8607 SEA PINES LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3321
Mailing Address - Country:US
Mailing Address - Phone:419-463-0023
Mailing Address - Fax:
Practice Address - Street 1:6438 WILMINGTON PIKE STE 205
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-7023
Practice Address - Country:US
Practice Address - Phone:937-848-1116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0234241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0054438Medicaid