MEDICARE: BRET J TUCKER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	144126-9921	UT

General Provider Information

NPI Number	:	1962671495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRET J TUCKER DDS

Provider Business Mailing Address
First Line	:	PO BOX 271069
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-1069
Country	:	US
Telephone Number	:	801-886-9341
Fax Number	:	801-886-1786

Provider Business Practice Location Address
First Line	:	1953 CALIFORNIA AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-4100
Country	:	US
Telephone Number	:	801-886-9341
Fax Number	:	801-886-1786

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	02/28/2008

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