Healthcare Provider Details

I. General information

NPI: 1730306721
Provider Name (Legal Business Name): ERIC M. ALLTUCKER DDSMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 BOYSEN AVE
SAN LUIS OBISPO CA
93405-1313
US

IV. Provider business mailing address

990 BOYSEN AVE
SAN LUIS OBISPO CA
93405-1313
US

V. Phone/Fax

Practice location:
  • Phone: 805-541-3220
  • Fax: 805-541-3704
Mailing address:
  • Phone: 805-541-3220
  • Fax: 805-541-3704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD46732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: