Provider Demographics
NPI:1669608741
Name:PUCKETT DENTAL LLC
Entity type:Organization
Organization Name:PUCKETT DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HARTLEY
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:870-236-5888
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72451-1209
Mailing Address - Country:US
Mailing Address - Phone:870-236-5888
Mailing Address - Fax:870-236-6888
Practice Address - Street 1:624 W COURT ST
Practice Address - Street 2:SUITE A
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4247
Practice Address - Country:US
Practice Address - Phone:870-236-5888
Practice Address - Fax:870-236-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176117631Medicaid