Provider Demographics
NPI:1619981859
Name:TUCKER, TODD S (DMD,MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:S
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DMD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S GARDEN WAY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-686-9750
Mailing Address - Fax:541-485-5034
Practice Address - Street 1:330 S GARDEN WAY
Practice Address - Street 2:SUITE 140
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-686-9750
Practice Address - Fax:541-485-5034
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73251223S0112X
OR220031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295498Medicaid
OR190009241OtherPALMETTO
OR288056Medicaid
OR104084Medicare ID - Type Unspecified
OR190009241OtherPALMETTO
104084Medicare PIN
OR295498Medicaid