Provider Demographics
NPI:1669567756
Name:TUCKER, CHARLES R (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
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 1:515 COLLEGE AVE. P.O. BOX 388
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717
Mailing Address - Country:US
Mailing Address - Phone:580-327-2277
Mailing Address - Fax:580-327-3223
Practice Address - Street 1:515 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-2202
Practice Address - Country:US
Practice Address - Phone:580-327-2277
Practice Address - Fax:580-327-3223
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3416OtherOKLAHOMA STATE LICENSE
KS075021OtherBC/BS OF KANSAS PROVIDER