Provider Demographics
NPI:1790165702
Name:TUCKER, TRAVIS CRAIG (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:CRAIG
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 1:1425 VICTOR AVE STE A
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-4857
Mailing Address - Country:US
Mailing Address - Phone:717-267-0800
Mailing Address - Fax:
Practice Address - Street 1:1425 VICTOR AVE STE A
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-4857
Practice Address - Country:US
Practice Address - Phone:717-267-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040406122300000X, 1223G0001X
CA1000191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist