Healthcare Provider Details

I. General information

NPI: 1104904036
Provider Name (Legal Business Name): ALAN C. TUCKER, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639A BEAVER RUIN RD NW
LILBURN GA
30047-3401
US

IV. Provider business mailing address

639A BEAVER RUIN RD NW
LILBURN GA
30047-3401
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-5200
  • Fax: 770-564-0613
Mailing address:
  • Phone: 770-923-5200
  • Fax: 770-564-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10864
License Number StateGA

VIII. Authorized Official

Name: DR. ALAN CHARLES TUCKER
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 770-923-5200