Provider Demographics
NPI:1134590219
Name:TUCKER, SHERYL LYNN (RDH)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:LYNN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5064 15 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-9158
Mailing Address - Country:US
Mailing Address - Phone:616-648-6349
Mailing Address - Fax:
Practice Address - Street 1:101 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4262
Practice Address - Country:US
Practice Address - Phone:616-776-2363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902004379124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist