Healthcare Provider Details

I. General information

NPI: 1871100982
Provider Name (Legal Business Name): ANDREA ALEXIS TUCKER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N TELEGRAPH RD
PONTIAC MI
48341-1029
US

IV. Provider business mailing address

5734 WOODLAND VW
CLARKSTON MI
48346-2637
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-1800
  • Fax:
Mailing address:
  • Phone: 810-265-3986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901600633
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: