Healthcare Provider Details

I. General information

NPI: 1144219643
Provider Name (Legal Business Name): STEVEN R. TUCKER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST STE D214A
LEXINGTON KY
40536-6048
US

IV. Provider business mailing address

100 SOMERSLY PL
LEXINGTON KY
40515-5717
US

V. Phone/Fax

Practice location:
  • Phone: 270-485-2762
  • Fax:
Mailing address:
  • Phone: 270-485-2762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number4475
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4475
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: