Provider Demographics
NPI:1871718833
Name:STEVEN R. TUCKER P.S.C.
Entity type:Organization
Organization Name:STEVEN R. TUCKER P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-926-4107
Mailing Address - Street 1:909 SCHERM RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6048
Mailing Address - Country:US
Mailing Address - Phone:270-926-4107
Mailing Address - Fax:270-926-4166
Practice Address - Street 1:909 SCHERM RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6048
Practice Address - Country:US
Practice Address - Phone:270-926-4107
Practice Address - Fax:270-926-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64044753Medicaid
KY60044757Medicaid
KY000000208416OtherBLUECROSS
KY65912016Medicaid
KYT54019Medicare UPIN
KY0759801Medicare ID - Type UnspecifiedMEDICARE