=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144219643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN R. TUCKER D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2005
-----------------------------------------------------
Last Update Date | 04/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 ROSE ST STE D214A
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40536-6048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-485-2762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 SOMERSLY PL
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40515-5717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-485-2762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 4475
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 4475
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------