Provider Demographics
NPI:1306235577
Name:TUCKER, BRENDA J (CDA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:TUCKER
Suffix:
Gender:F
Credentials:CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7058 CORPORATE WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4295
Mailing Address - Country:US
Mailing Address - Phone:937-586-7729
Mailing Address - Fax:
Practice Address - Street 1:7058 CORPORATE WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4295
Practice Address - Country:US
Practice Address - Phone:937-586-7729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH51006003126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant