Healthcare Provider Details

I. General information

NPI: 1467899823
Provider Name (Legal Business Name): GARY EDWIN TUCKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2013
Last Update Date: 05/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2489 DISCOVERY BAY BLVD STE 400
DISCOVERY BAY CA
94505-1008
US

IV. Provider business mailing address

1932 WINDWARD PT
DISCOVERY BAY CA
94505-9510
US

V. Phone/Fax

Practice location:
  • Phone: 925-634-6111
  • Fax:
Mailing address:
  • Phone: 925-634-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: