Healthcare Provider Details

I. General information

NPI: 1548725765
Provider Name (Legal Business Name): S. ADAM TACKETT, DMD, MS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 W CUMBERLAND GAP PKWY STE D
CORBIN KY
40701-5194
US

IV. Provider business mailing address

727 W CUMBERLAND GAP PKWY STE D
CORBIN KY
40701-5194
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN ADAM TACKETT
Title or Position: ORTHODONTIST
Credential: DMD, MS
Phone: 606-523-2000