Healthcare Provider Details

I. General information

NPI: 1972578789
Provider Name (Legal Business Name): W. MARK TUCKER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

IV. Provider business mailing address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-7511
  • Fax: 813-910-4038
Mailing address:
  • Phone: 813-972-7511
  • Fax: 813-910-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN0006497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: