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General NPI Number Information
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NPI Number | 1508298019
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Entity Type | Individual
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Provider Name | BRADLEY WILLIAM TUCKER DDS
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Gender | Male
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Dates
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Enumeration Date | 08/07/2013
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Last Update Date | 08/07/2013
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Provider Practice Location Address
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Address Line | 940 BLACK CANYON WAY
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City | MONTROSE
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State | CO
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Zip | 81403-9833
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Country | US
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Telephone | 360-820-1407
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Fax |
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Provider Business Mailing Address
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Address Line | 940 BLACK CANYON WAY
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City | MONTROSE
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State | CO
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Zip | 81403-9833
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Country | US
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Telephone | 360-820-1407
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DEN.00202056
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License Number State | CO
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