Provider Demographics
NPI:1598817694
Name:TUCKER, RANDALL D (DMD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
Last Name:TUCKER
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 1:166 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810
Mailing Address - Country:US
Mailing Address - Phone:978-475-8656
Mailing Address - Fax:978-470-2788
Practice Address - Street 1:166 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-475-8656
Practice Address - Fax:978-470-2788
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159131223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics