Healthcare Provider Details

I. General information

NPI: 1790165702
Provider Name (Legal Business Name): TRAVIS CRAIG TUCKER D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 VICTOR AVE STE A
REDDING CA
96003-4857
US

IV. Provider business mailing address

1425 VICTOR AVE STE A
REDDING CA
96003-4857
US

V. Phone/Fax

Practice location:
  • Phone: 530-222-0920
  • Fax: 530-222-0921
Mailing address:
  • Phone: 530-222-0920
  • Fax: 530-222-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS040406
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number100019
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS040406
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: