Provider Demographics
NPI:1831252840
Name:TUCKER, JONATHAN DANIEL (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
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 1:2504 HILLTOP ST
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-1600
Mailing Address - Country:US
Mailing Address - Phone:512-260-9333
Mailing Address - Fax:512-260-9331
Practice Address - Street 1:10703 E. CRYSTAL FALLS PKWY
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-2259
Practice Address - Country:US
Practice Address - Phone:512-260-9333
Practice Address - Fax:512-260-9331
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173246301Medicaid