Provider Demographics
NPI:1962577338
Name:TUCKER, DENNIS MAXWELL (DDS)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MAXWELL
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 1:622 ROOSEVELT RD 180
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-6361
Mailing Address - Country:US
Mailing Address - Phone:320-259-5078
Mailing Address - Fax:
Practice Address - Street 1:622 ROOSEVELT RD
Practice Address - Street 2:STE 180
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6153
Practice Address - Country:US
Practice Address - Phone:320-259-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114101223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics