Provider Demographics
NPI:1285767376
Name:TUCK, ROBERT JEFFREY (DMD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JEFFREY
Last Name:TUCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2507
Mailing Address - Country:US
Mailing Address - Phone:508-583-3377
Mailing Address - Fax:508-583-0811
Practice Address - Street 1:567 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2507
Practice Address - Country:US
Practice Address - Phone:508-583-3377
Practice Address - Fax:508-583-0811
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA113971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX04783OtherBLUE CROSS BLUE SHIELD MA