Healthcare Provider Details

I. General information

NPI: 1639305170
Provider Name (Legal Business Name): WILLIAM ALAN PUCKETT JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 PETERMAN DR
ALEXANDRIA LA
71301-3432
US

IV. Provider business mailing address

1408 PETERMAN DR
ALEXANDRIA LA
71301-3432
US

V. Phone/Fax

Practice location:
  • Phone: 318-427-9220
  • Fax: 318-442-1811
Mailing address:
  • Phone: 318-427-9220
  • Fax: 318-442-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5978
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: