Provider Demographics
NPI:1942303813
Name:TUCKER, BRADFORD GARRISON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:GARRISON
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 1:801 CRESCENT WAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6780
Mailing Address - Country:US
Mailing Address - Phone:707-822-2711
Mailing Address - Fax:707-822-0885
Practice Address - Street 1:801 CRESCENT WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6780
Practice Address - Country:US
Practice Address - Phone:707-822-2711
Practice Address - Fax:707-822-0885
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA333901223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB33390-01OtherDENTI-CAL