Provider Demographics
NPI:1639288574
Name:TUCKER, BURRELL L (DDS)
Entity Type:Individual
Prefix:
First Name:BURRELL
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N DAL PASO ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-4041
Mailing Address - Country:US
Mailing Address - Phone:505-393-5117
Mailing Address - Fax:505-397-4967
Practice Address - Street 1:1400 N DAL PASO ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-4041
Practice Address - Country:US
Practice Address - Phone:505-393-5117
Practice Address - Fax:505-397-4967
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice