Provider Demographics
NPI:1790393833
Name:TUCKER, KRISTAL AMALIA (DDS)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:AMALIA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2748 W ARLINGTON BLVD APT 307
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4092
Mailing Address - Country:US
Mailing Address - Phone:910-545-3937
Mailing Address - Fax:
Practice Address - Street 1:1851 MACGREGOR DOWNS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5925
Practice Address - Country:US
Practice Address - Phone:252-737-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC119501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice