Provider Demographics
NPI:1609100593
Name:TUCKER, TAYLOR LOGAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:LOGAN
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 1:2455 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7756
Mailing Address - Country:US
Mailing Address - Phone:334-872-0486
Mailing Address - Fax:
Practice Address - Street 1:2455 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7756
Practice Address - Country:US
Practice Address - Phone:334-872-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8864122300000X
AL5723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5723OtherSTATE LICENSE
NC8864OtherSTATE LICENSE