Provider Demographics
NPI:1952454084
Name:TUCKER, MONIQUE CURRIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONIQUE
Middle Name:CURRIE
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 1:301 THATCHER AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-2031
Mailing Address - Country:US
Mailing Address - Phone:708-865-0200
Mailing Address - Fax:708-865-1730
Practice Address - Street 1:2133 S 17TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3019
Practice Address - Country:US
Practice Address - Phone:708-865-0200
Practice Address - Fax:708-865-1730
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0238031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004349Medicaid
IL170373Medicaid