Provider Demographics
NPI:1730320433
Name:TUCKER, GARY RODERICK JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RODERICK
Last Name:TUCKER
Suffix:JR
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 1:1101 MASON FARM RD APT 314
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-3949
Mailing Address - Country:US
Mailing Address - Phone:919-914-0313
Mailing Address - Fax:
Practice Address - Street 1:5501 FORTUNES RIDGE DR STE H
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6102
Practice Address - Country:US
Practice Address - Phone:919-493-8944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics