Provider Demographics
NPI:1629007505
Name:DAVIDSON- TUCKER ORAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:DAVIDSON- TUCKER ORAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, DAVIDSON-TUCKER ORAL SUR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:724-483-5080
Mailing Address - Street 1:17 ARENTZEN BLVD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022-1085
Mailing Address - Country:US
Mailing Address - Phone:724-483-5080
Mailing Address - Fax:724-483-3760
Practice Address - Street 1:17 ARENTZEN BLVD
Practice Address - Street 2:SUITE #104
Practice Address - City:CHARLEROI
Practice Address - State:PA
Practice Address - Zip Code:15022-1085
Practice Address - Country:US
Practice Address - Phone:724-483-5080
Practice Address - Fax:724-483-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026650-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0525357Medicaid
PA101208Medicare ID - Type Unspecified