Provider Demographics
NPI:1952598310
Name:TUCKER & ALLEN-JOHNSON DDS PA
Entity Type:Organization
Organization Name:TUCKER & ALLEN-JOHNSON DDS PA
Other - Org Name:SMILE JUNCTION PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:GIOVONNE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-538-1608
Mailing Address - Street 1:2975 CROUSE LANE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8833
Mailing Address - Country:US
Mailing Address - Phone:336-538-1608
Mailing Address - Fax:
Practice Address - Street 1:2975 CROUSE LANE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8833
Practice Address - Country:US
Practice Address - Phone:336-538-1608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902TVMedicaid
NC019VYOtherNORTH CAROLINA HEALTH CHOICE/GROUP
NC0902UHOtherNORTH CAROLINA HEALTH CHOICE/INDIVIDUAL
NC092TVOtherNORTH CAROLINA HEALTH CHOICE/INDIVIDUAL