Provider Demographics
NPI:1730306721
Name:ALLTUCKER, ERIC M (DDSMD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:ALLTUCKER
Suffix:
Gender:M
Credentials:DDSMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 BOYSEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1313
Mailing Address - Country:US
Mailing Address - Phone:805-541-3220
Mailing Address - Fax:805-541-3704
Practice Address - Street 1:990 BOYSEN AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1313
Practice Address - Country:US
Practice Address - Phone:805-541-3220
Practice Address - Fax:805-541-3704
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD467321223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery