MEDICARE: TUCKER WILLIAM GROSS RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH1175	SD

General Provider Information

NPI Number	:	1235577495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TUCKER WILLIAM GROSS RDH

Provider Business Mailing Address
First Line	:	1306 S LAKE DR
Second Line	:
City	:	WATERTOWN
State	:	SD
Zip	:	57201-5450
Country	:	US
Telephone Number	:	605-222-4489
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 S LAKE DR
Second Line	:
City	:	WATERTOWN
State	:	SD
Zip	:	57201-5450
Country	:	US
Telephone Number	:	605-222-4489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2013
Last Update Date	:	06/10/2013

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