Healthcare Provider Details

I. General information

NPI: 1922471622
Provider Name (Legal Business Name): DEAN PUCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 S VANDEVENTER AVE STE 700
SAINT LOUIS MO
63110-3842
US

IV. Provider business mailing address

1027 S VANDEVENTER AVE STE 700
SAINT LOUIS MO
63110-3842
US

V. Phone/Fax

Practice location:
  • Phone: 314-203-1431
  • Fax:
Mailing address:
  • Phone: 314-203-1431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberMONAVD3300006
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: