Healthcare Provider Details

I. General information

NPI: 1043694920
Provider Name (Legal Business Name): PUCKETT DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 HIGHWAY 67 NORTH
POCAHONTAS AR
72455
US

IV. Provider business mailing address

1041HWY. 67 N.
POCAHONTAS AR
72455
US

V. Phone/Fax

Practice location:
  • Phone: 870-236-5888
  • Fax:
Mailing address:
  • Phone: 870-236-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number4053
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3684
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3406
License Number StateAR

VIII. Authorized Official

Name: DR. JOHN HARTLEY PUCKETT
Title or Position: OWNER
Credential: D.D.S.
Phone: 870-236-5888