Provider Demographics
NPI:1104904036
Name:ALAN C. TUCKER, D.D.S., P.C.
Entity type:Organization
Organization Name:ALAN C. TUCKER, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-923-5200
Mailing Address - Street 1:639A BEAVER RUIN RD NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3401
Mailing Address - Country:US
Mailing Address - Phone:770-923-5200
Mailing Address - Fax:770-564-0613
Practice Address - Street 1:639A BEAVER RUIN RD NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:770-923-5200
Practice Address - Fax:770-564-0613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UL26295Medicare UPIN
19NCBJDMedicare ID - Type Unspecified