Healthcare Provider Details

I. General information

NPI: 1578666426
Provider Name (Legal Business Name): JOHN C TACKETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N HARRISON ST
SALEM IN
47167-1426
US

IV. Provider business mailing address

102 N HARRISON ST
SALEM IN
47167-1426
US

V. Phone/Fax

Practice location:
  • Phone: 812-883-4281
  • Fax: 812-883-4289
Mailing address:
  • Phone: 812-883-4281
  • Fax: 812-883-4289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12009512A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: