Provider Demographics
NPI:1932418092
Name:TUCKER, SID MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:SID
Middle Name:MICHAEL
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 ROUTE 304
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954
Mailing Address - Country:US
Mailing Address - Phone:845-623-6666
Mailing Address - Fax:
Practice Address - Street 1:446 ROUTE 304
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954
Practice Address - Country:US
Practice Address - Phone:845-623-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0488141223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics