Provider Demographics
NPI:1962554535
Name:TUCKER, MICHAEL RANDOLPH (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RANDOLPH
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 1:502 PRAIRIE
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295
Mailing Address - Country:US
Mailing Address - Phone:318-435-6155
Mailing Address - Fax:318-435-6155
Practice Address - Street 1:502 PRAIRIE
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295
Practice Address - Country:US
Practice Address - Phone:318-435-6155
Practice Address - Fax:318-435-6155
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1821624Medicaid