Healthcare Provider Details

I. General information

NPI: 1326163296
Provider Name (Legal Business Name): GAIL M TUCKER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 BAKER AVE
WEBSTER GROVES MO
63119
US

IV. Provider business mailing address

7 HAZEL TRAIL CT
FENTON MO
63026-4209
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-1160
  • Fax: 314-961-7822
Mailing address:
  • Phone: 636-677-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0000442
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: